Video Atlas of Pediatric Endosurgery (VAPE): A Step-By-Step Approach to Common Operations 3030580423, 9783030580421

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Martin Lacher Oliver J. Muensterer  Editors

Video Atlas of Pediatric Endosurgery (VAPE) A Step-By-Step Approach to Common Operations

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Video Atlas of Pediatric Endosurgery (VAPE)

Martin Lacher  •  Oliver J. Muensterer Editors

Video Atlas of Pediatric Endosurgery (VAPE) A Step-By-Step Approach to Common Operations

Editors Martin Lacher Department of Pediatric Surgery University Hospital of Leipzig Leipzig Germany

Oliver J. Muensterer Department of Pediatric Surgery Dr. von Hauner Children’s Hospital Ludwig-Maximilians-University Munich Munich Germany

This work contains media enhancements, which are displayed with a “play” icon. Material in the print book can be viewed on a mobile device by downloading the Springer Nature “More Media” app available in the major app stores. The media enhancements in the online version of the work can be accessed directly by authorized users. ISBN 978-3-030-58042-1    ISBN 978-3-030-58043-8 (eBook) https://doi.org/10.1007/978-3-030-58043-8 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Oliver Muensterer joined our pediatric endosurgery fellowship program at the Children’s Hospital of Alabama virtually unknown to our children’s surgery staff. His residency training in pediatric surgery had been acquired in Munich, Germany, where our faculty had no academic acquaintances. Oliver merged seamlessly into our residency program and quickly distinguished himself by his prodigious energy and exceptional surgical talent. We later invited him to join our surgical group, where he flourished and recruited Martin Lacher as our pediatric endosurgery fellows. He subsequently went on to New York City and eventually returned to Germany where the promise we recognized in him has continued to propel him forward, both clinically and academically. Both Oliver Muensterer and Martin Lacher now again joined forces to produce what should become a landmark pediatric endosurgery reference work. Minimally invasive pediatric surgery has firmly established its important role in the children’s surgery toolbox. Pediatric endosurgery has joined surgical quality and safety, enhanced recovery after surgery (ERAS), standardized antibiotic strategies, and improved pain management protocols as major factors in the improved outcomes currently being achieved after operative procedures on children. Due to its dependence on evolving technologies, improved techniques and different skill sets, pediatric endosurgery utilizes frequent updates to propagate recent progress. This atlas is an excellent example of the latest advances in children’s endoscopic surgery. From its inception, minimally invasive pediatric surgery has greatly benefited from its international talent pool. As the program director for the first International Pediatric Endosurgery Group (IPEG) meeting (in Orlando, Florida in 1995), I recall with great wonder the clever and novel techniques contributed by pediatric surgeons representing countries from all over the world. This atlas with accompanying videos is another example of the international community of pediatric surgeons cooperating to update the current state of the art in pediatric endosurgery. I commend it to you. Keith Georgeson Chief Executive of Children’s Services Providence Sacred Heart Medical Center Spokane, Washington, USA

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Foreword

Since the breakthrough of minimally invasive pediatric surgery about thirty years ago, our pediatric surgical world has changed substantially. Today, most types of operations in children may be performed endoscopically and the new techniques have become routine in most centers worldwide. However, many aspects are still under debate. They include particularly technical issues, teaching, and training. Both editors are masters of the field. They have focused their career on minimally invasive pediatric surgery and have gained substantial experience. They conducted numerous workshops and performed minimally invasive teaching operations in many countries all over the world. This book reflects the competence and enthusiasm of the editors. Following numerous textbooks, the editors of the present book concentrate on the state of the art of indications, positioning of patients, operative steps, technical aspects of operation, and the management of complications. The whole spectrum of endoscopic pediatric surgery is covered using a step-by-step approach. Milestones of abdominal, gastrointestinal, colorectal, thoracic, and urological operations are presented. Corresponding videos of each type of operation dealing with maneuvers, tips, and alternative approaches are accessible through different devices including computers, tablets, and smartphones. Therefore, the format and layout of this book are truly innovative. Many experts of the field have contributed with great enthusiasm to an impressive number of fifty chapters. It was a pleasure to participate in the project also for the Hannover team. I warmly recommend this book to all pediatric surgeons. It will further promote minimally invasive surgery and make life easier for those who are in training and for advanced colleagues all over the world. Benno Ure Hannover Medical School Hannover, Germany

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Preface

The field of pediatric surgery comprises a vast spectrum of surgical interventions. In modern days, most of these can and should be performed via minimally invasive endosurgical techniques, since they limit or eliminate the collateral damage inflicted by open surgical incisions. Since the learning curve is longer for most endosurgical operations, compared to their open traditional counterparts, it is essential that surgeons and trainees have access to resources that demonstrate the techniques in a concrete and illustrative manner. Since individual pediatric surgical indications are often rare, it is also invaluable to provide tips and tricks that can only be accumulated through extensive experience, along with pitfalls that can be avoided if anticipated. In contrast to standard textbooks, this video atlas of pediatric endosurgery is designed to give an in-depth overview of a particular operation using a combination of a short video with meaningful illustrations and a short descriptive text. The chapters and videos can be accessed anytime and anywhere, allowing the surgeon readers to systematically learn new skills at leisure or acutely update their technique before a scheduled procedure. Breaking down the operation into fundamental milestones further enhances the experience. We hope that this video atlas provides both established pediatric surgeons and trainees with the resource they need to provide the best possible care to their patients. Leipzig, Germany Munich, Germany 

Martin Lacher Oliver J. Muensterer

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Contents

Part I Foregut 1 Laparoscopic Nissen Fundoplication �����������������������������������������������������������������������   3 Takafumi Kawano and Oliver J. Muensterer 2 Laparoscopic Toupet Fundoplication�����������������������������������������������������������������������   9 Yew-Wei Tan, Illya Martynov, Martin Lacher, and Amulya K. Saxena 3 Laparoscopic Thal Fundoplication���������������������������������������������������������������������������  13 Jan H. Gosemann, Illya Martynov, and Martin Lacher 4 Laparoscopic Heller Myotomy ���������������������������������������������������������������������������������  19 Lea Sibylle Waldron and Oliver J. Muensterer 5 Foregut Duplication or Esophageal Duplication �����������������������������������������������������  23 Yury Kozlov, Alexander Razumovsky, and Alexander Smirnov 6 Nutritional Access Procedures�����������������������������������������������������������������������������������  27 Stephan Rohleder and Takafumi Kawano 7 Laparoscopic Pyloromyotomy�����������������������������������������������������������������������������������  33 Steffi Mayer, Illya Martynov, and Martin Lacher 8 Laparoscopic Duodenal Atresia Repair �������������������������������������������������������������������  37 Oliver J. Muensterer and Andreas Lindner Part II Small Intestine 9 Laparoscopic Approach to Malrotation�������������������������������������������������������������������  43 Vikas Gupta and Samir Pandya 10 Laparoscopic Treatment of Intussusception�������������������������������������������������������������  47 Evgenij Werner and Oliver J. Muensterer 11 Laparoscopic Management in Crohn’s Disease: Ileocecal Resection���������������������  51 Laura Saura and Xavier Tarrado Part III Colorectal 12 Laparoscopic Appendicectomy ���������������������������������������������������������������������������������  59 Ibrahim A. Mostafa and Mohamed Sameh Shalaby 13 Single Incision Pediatric Endosurgical (SIPES) Appendectomy ���������������������������  63 Tatjana T. König and Oliver J. Muensterer 14 Single-Incision Pediatric Endosurgical (SIPES) Appendectomy using a Glove Port�������������������������������������������������������������������������������������������������������  69 Illya Martynov and Martin Lacher xi

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15 Laparoscopic Management in Ulcerative Colitis: Staged Proctocolectomy with Ileal Pouch-Anal Anastomosis���������������������������������  75 Pedro Palazón and Xavier Tarrado 16 Laparoscopic Approach in Anorectal Malformations���������������������������������������������  83 Alejandra Vilanova-Sánchez, Richard J. Wood, Carlos A. Reck-Burneo, Devin R. Halleran, and Marc A. Levitt 17 Laparoscopic Approach to Hirschsprung Disease���������������������������������������������������  89 Alejandra Vilanova-Sánchez, Richard J. Wood, Carlos A. Reck-Burneo, Devin R. Halleran, and Marc A. Levitt Part IV Hepatobiliary 18 Laparoscopic Cholecystectomy���������������������������������������������������������������������������������  97 Nadia Guardado, Trenton Burgess, and Lena Perger 19 Laparoscopic cholangiography and Liver Biopsy��������������������������������������������������� 101 Jessica Zagory and Samir Pandya 20 Laparoscopic Kasai Portoenterostomy for Biliary Atresia������������������������������������� 105 Go Miyano, Hiroyuki Koga, and Atsuyuki Yamataka 21 Laparoscopic Resection of Choledochal Cyst with Hepaticojejunostomy������������� 109 Martin Lacher, Tatjana T. König, Alexander Sterlin, and Oliver J. Muensterer 22 Laparoscopic Splenectomy����������������������������������������������������������������������������������������� 117 Spyros P. Spyrakos, Edward Riachy, and Sophia Delicou 23 Single Incision Pediatric Endosurgical (SIPES) Splenectomy������������������������������� 123 Jan Goedeke and Oliver J. Muensterer 24 Laparoscopic Partial Splenectomy ��������������������������������������������������������������������������� 131 Peter Zimmermann, Illya Martynov, and Martin Lacher Part V Oncology 25 General Oncologic Endosurgical Procedures����������������������������������������������������������� 137 Lucas Krauel, Rosalia Carrasco, and Margarita Vancells 26 Laparoscopic Adrenalectomy������������������������������������������������������������������������������������� 143 Christoph Zoeller, Benno Ure, Joachim F. Kuebler, and Jens Dingemann 27 Ovarian Procedures: Laparoscopic Ovarian Preserving Cystectomy and Laparoscopic Detorsion ������������������������������������������������������������������������������������� 147 Thomas M. Benkoe and Martin L. Metzelder 28 Laparoscopic-Assisted Mobilization and Resection of a Sacrococcygeal Teratoma����������������������������������������������������������������������������������� 151 Jan Goedeke and Oliver. J. Muensterer Part VI Hernias 29 Laparoscopic Herniorrhaphy ����������������������������������������������������������������������������������� 161 Illya Martynov and Martin Lacher 30 Laparoscopic Epigastric Hernia Repair������������������������������������������������������������������� 167 Anne-Sophie Holler and Oliver J. Muensterer

Contents

Contents

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Part VII Urology 31 Laparoscopic Pyeloplasty������������������������������������������������������������������������������������������� 173 Gabriel Goetz, Illya Martynov, and Martin Lacher 32 Laparoscopic Transperitoneal Simple Nephrectomy����������������������������������������������� 179 Illya Martynov, Christoph Zoeller, Joachim F. Kuebler, and Martin Lacher 33 Laparoscopic Transperitoneal Heminephrectomy��������������������������������������������������� 183 Illya Martynov, Christoph Zoeller, Joachim F. Kuebler, and Martin Lacher 34 Extravesical Ureteral Reimplantation (Lich-Gregoir) ������������������������������������������� 187 Ciro Esposito, Mariapina Cerulo, Fulvia Del Conte, Vincenzo Coppola, and Maria Escolino 35 Laparoscopic Varicocelectomy����������������������������������������������������������������������������������� 191 Robin Wachowiak, Illya Martynov, and Martin Lacher 36 Laparoscopic Orchidopexy ��������������������������������������������������������������������������������������� 195 Takafumi Kawano and Satoshi Ieiri 37 Laparoscopic Management of Intra-abdominal Testis (Shehata Technique)������� 199 Sameh Shehata 38 Two Stage Laparoscopic Assisted Fowler-Stephens Orchidopexy������������������������� 205 Sameh Abdelhay and Amr Abdelhamid AbouZeid Part VIII Thorax 39 Thoracoscopic Tracheoesophageal Fistula and Esophageal Atresia Repair������������������������������������������������������������������������������������������������������������� 213 Sarah W. Lai and Steve Rothenberg 40 Thoracoscopic Technique Using Internal Traction Sutures for Long-Gap Esophageal Atresia Repair ��������������������������������������������������������������� 219 Dariusz Patkowski 41 Thoracoscopic Tracheoesophageal H-Type Fistula Repair������������������������������������� 223 Anne-Sophie Holler and Oliver J. Muensterer 42 Thoracoscopic Lung Biopsy��������������������������������������������������������������������������������������� 227 Jens Dingemann, Benno Ure, Joachim F. Kuebler, and Christoph Zoeller 43 Thoracoscopic Lung Resection ��������������������������������������������������������������������������������� 231 Sarah W. Lai and Steve Rothenberg 44 Treatment for Spontaneous Pneumothorax������������������������������������������������������������� 235 Federico G. Seifarth and Oliver J. Muensterer 45 Pulmonary Sequestrations����������������������������������������������������������������������������������������� 239 Peter Zimmermann, Illya Martynov, and Martin Lacher 46 Video-Assisted Thoracoscopic Approach for Mediastinal Mass (VATS)��������������� 243 Alexander Sterlin, Oliver J. Muensterer, and Jan Goedeke 47 Thoracoscopic Thymectomy ������������������������������������������������������������������������������������� 249 Phillip Benson Ham III, Walter Pipkin, Kosmas Iliadis, and Spyros P. Spyrakos

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48 Thoracoscopic and Laparoscopic Approaches to Congenital Diaphragmatic Hernia (CDH)����������������������������������������������������������������������������������� 255 Satoshi Ieiri, Kazuhiko Nakame, and Koji Yamada 49 Minimally Invasive Repair of Pectus Excavatum (MIRPE)����������������������������������� 261 Sergio B. Sesia and Gregor J. Kocher 50 Thoracoscopic Sympathotomy with Sympathicolysis (TS) for Primary Palmar Hyperhidrosis (PPH) in Children������������������������������������������� 267 Adam Mol

Contents

Part I Foregut

1

Laparoscopic Nissen Fundoplication Takafumi Kawano and Oliver J. Muensterer

1.1

Indications for Fundoplication

Gastroesophageal reflux (GER) is a common phenomenon in children, occurring in 7–20% of pediatric population [1]. The symptom of GER usually becomes less frequent with time and they are known to resolve in 90% of affected infants before they turn 1 year old. The treatment of pediatric GER has wide range of spectrum from a conservative treatment, such as diet modifications and medication, to surgical treatment [2]. Fundoplication in infants, children and young people is considered for the patient with symptomatic reflux that has failed appropriate medical management, particularly in cases with failure to thrive, airway symptoms, or signs of esophagitis. Since long-term conservative treatment can be impracticable in the severely neurologically impaired patient with GER, that patient who requires a gastrostomy for feeding may also benefit from a fundoplication at the same time in certain circumstances. In addition, GER is known to be associated with apparent life-threatening events (ALTEs), and the children with ALTEs and no other etiology may also benefit from fundoplication without a trial of medical treatment. However, the risk of surgical treatment, postoperative complications, recurrence of GER and other problems canSupplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_1. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. T. Kawano (*) Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan e-mail: [email protected] O. J. Muensterer Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

not be neglected. Nearly 20% of patients require a redo of the fundoplication and the overall recurrence rate of symptoms varies between 5% and 15% in different studies [3]. The careful selection of patients is therefore a key process in children, and when deciding on surgical treatment, it is necessary to consider how much improvement is expected in the quality of life of the patient by the fundoplication.

1.2

Preoperative Workup and Considerations

A detailed history should be obtained preoperatively. According to current guidelines of gastroesophageal reflux, any given test alone is insufficient to make a definitive diagnosis of GER.  Therefore, in children, the decision to treat GER should result from integration of the results of the clinical symptoms, supplemented by carefully selected diagnostic tests that are useful to rule out other diseases. Most surgeons perform an upper gastrointestinal contrast study to evaluate the anatomy, although some current guidelines question this approach [4]. The most useful aspect of this test is to rule out other anatomic abnormalities of the upper gastrointestinal tract, such as malrotation, duodenal stenosis and esophageal strictures. Twenty-four-hour pH probe testing has been considered the gold standard for diagnosing GERD since the 1980s in adults. Unfortunately, there are no absolute threshold values for children. Currently, multiple intraluminal impedance pH monitoring are performed in clinical settings to evaluate the presence of GER since they can measure nonacidic reflux and can be performed while children are on anti-acid medications, such as H2 blockers, as well. Other diagnostic tests such as upper endoscopy with biopsies, and gastric emptying studies may also be performed to investigate further. However, the lack of standardized normal values in children and these tests leaves much room for interpretation. In the end, the clinical symptoms need to guide the surgeon on whether a fundoplication is indicated or not.

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_1

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T. Kawano and O. J. Muensterer

1.3

Anesthetic Considerations

1.4.2 Positioning

Laparoscopic fundoplication is typically performed under general anesthesia and endotracheal intubation. Since many of these patients have associated anomalies, these cases should be performed by experienced pediatric anesthesiologists. Intraoperative bleeding is rare but having blood available is advisable for special circumstances, such as redo-procedures. At least 1 peripheral intravenous catheter should be available. Single-shot antimicrobial prophylaxis with Ampicillin/Sulbactam is advisable.

The patient is placed at the end of the table. Infants are placed in a frog-leg position and the older children can be placed supine in low lithotomy position with the lower extremities extended on stirrups with appropriate padding. A monitor is placed over the patient’s head, and an orogastric or a nasogastric tube is placed by the anesthesiologist. The surgeon will stand between the patient’s leg or at the foot of the bed, and the first and second assistants on the left and right side of the table, respectively (Fig. 1.1).

1.4

1.4.3 Trocar Placement

Operative Technique

1.4.1 Equipment • • • • • • • • • •

3 or 5 mm instruments and trocars 3 mm or 5 mm 30° laparoscope 3 or 5 mm Maryland dissector 3 or 5 mm atraumatic grasper 3 or 5 mm needle holder 3 or 5 mm Metzenbaum scissors 5 mm liver retractor 3 or 5 mm monopolar cautery (grounding pad) 3 or 5 mm Vessel sealing device (in older children) 2–0 braided nonabsorbable suture (to suspend the liver and to create the wrap)

Fig. 1.1  Positioning of patient, surgeons and monitors

The first trocar is placed at the umbilicus. The pneumoperitoneum is established using CO2 insufflation at a pressure between 8–12 mmHg and a CO2 flow of 4–10 l/min depends on patient’s age, body size and medical condition. During the procedure, the insufflation pressure and the flow can be increased temporarily to provide sufficient working space. Under inspection via the laparoscope, up to four more trocars are inserted as in the right and left upper-quadrants, a liver retractor port in the left upper quadrants near the mid line. The left upper quadrant trocar position is used as the optical port during the actual procedure, and becomes the gastrostomy tube site if patient undergoes gastrostomy after fundoplication at the same time. Many variations

Legend

Patient

Monitor Surgeon 1st Assistant 2nd Assistant Scrub nurse

Instrument table

1  Laparoscopic Nissen Fundoplication

including a single-site technique have been described [5]. However, the sequence of procedure is same, even though the number and the location of port site are different (Fig. 1.2).

1.4.4 Operative Milestones After placement of the trocars, the operation begins with liver retraction to obtain an optimal space and expose the gastrointestinal junction. There are many methods to achieve this. Conventionally, the left lobe of the liver is retracted superiorly through upper middle port by a liver retractor. A 2.4 mm grasper with a locking in-line handle can be used gripping the diaphragm to expose the hiatus. Since using retractor or grasper can have the confliction with operator’s forceps in small children and can damage the liver, the hepatic crown suture technique in which the liver is retracted by a surgical thread, may also be used. This technique can reduce the number of port site and minimalize damage to liver. It is important to select the appropriate method according to patients’ size and condition (Milestone 1.1). After the left segment of the liver is retracted and the gastroesophageal junction is exposed, the gastrohepatic lig-

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ament is divided retracting the stomach toward the left side by an assistant forceps. The dissection begins above the caudate lobe of the liver and continues proximally until the right crus is identified (Milestone 1.2). The stomach is then retracted to the right by an assistant forceps, and the short gastric vessels are divided. The division of the short gastric vessels will ensure a tension-free wrap. Dividing short gastric vessel with electrocautery is acceptable in infants, but may require a vessel sealing device in older children (Milestone 1.3). Bleeding from the gastric vessels or the spleen can be caused by transection of not yet completely sealed vessels in older children. During dissection, it is important to avoid damage of the gastric wall from electrocautery. The crus is then separated from the right side of the esophagus by blunt dissection, and a retro-esophageal window is created. The right crus can be dissected so that sufficient length of intra-abdominal esophagus is ensured. This window should be enlarged carefully not to injure the posterior vagus nerve (Milestone 1.4). A crural repair should be performed with a braided nonabsorbable suture when the hiatal opening is large (Milestone 1.5). A crural repair can decrease the postoperative hiatal hernia formation. The fun-

Legend

Working trocar Working trocar (gastrostomy site) Endoscope trocar Accessory trocar Trocar (retractor)

Fig. 1.2  Positioning of the trocars (e.g. 5 trocars)

Milestone 1.1  To obtain an optimal space and expose the gastrointestinal junction, the liver should be retracted. There are various methods, and it is important to select the appropriate method according to

Milestone 1.2  The stomach is retracted to the left by the assistant and the gastrohepatic ligament is dissected proximally until the right crus is identified

patients’ condition such as size and deformity (Video 1.1 1218 part2). (▸ https://doi.org/10.1007/000-2tt)

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Milestone 1.3  The stomach is then retracted to the right by an assistant forceps, and the short gastric vessels are divided with electrocautery or a vessel sealing device

Milestone 1.4  A retro-esophageal window is opened by blunt dissection from the right side of the esophagus and is enlarged carefully not to injure the posterior vagus nerve

T. Kawano and O. J. Muensterer

Milestone 1.5  The closure of the diaphragmatic crus is performed with interrupted non-absorbable suture

Milestone 1.6  The wrap is created with three sutures. The wrap should be approximately 2–3 cm, and loose wrap is advisable

1.5 dus is passed behind the esophagus and a shoeshine maneuver is performed to confirm sufficient mobilization of fundus and to assure that the stomach is not twisted. A fundoplication is created by placing three stitches of nonabsorbable material at approximately 1 cm intervals. Most surgeons use braided nonabsorbable sutures, such as silk or polyester. The sutures should also incorporate a small piece of anterior esophagus to avoid wrap migration. The wrap should be created about 2–3 cm in the length (Milestone 1.6). If a gastrostomy is placed at the same time, the trocar site in the left upper quadrant should be used for the gastrostomy site. A number of techniques may be performed for the gastrostomy tube placement (see chapter 6 Nutritional Access Procedures).

Postoperative Care

Feeding can be initiated on the first operative day and gradually increased to ad lib over the following days. Patients are kept on a no-chunk diet for approximately 2 weeks to avoid complaints of dysphagia due to post-operative edema around the fundoplication. Some patients experience transient dysphagia, which usually resolves after 6–10 weeks. Complications after laparoscopic Nissen fundoplication include hiatal hernia, slipped wrap, recurrent GER, persistent dysphagia, and gas bloat syndrome. The overall recurrence rate for symptomatic reflux after fundoplication ranges widely in the literature, but is generally around 5–15% and the most common causes of wrap failure are hiatal hernia and slipping of the wrap.

1  Laparoscopic Nissen Fundoplication

1.6

Pearls/Tips & Tricks

1. Divide the short gastric vessels to create a tension-free wrap. Dividing short gastric vessel with electrocautery is acceptable in infants, but a vessel sealing device is advisable in older children. 2. Mobilize an adequate length of intra-abdominal esophagus in children. 3. Crural repair should be performed when the hiatal opening is large. There have been no randomized controlled trials comparing closure with no closure of the crura, however, a crural repair in cases with the risk such as large hiatal opening can decrease the postoperative hiatal hernia formation [6]. 4. Minimal dissection of the phrenoesophageal ligaments decreases postoperative recurrence. 5. Perform a shoeshine maneuver to confirm sufficient mobilization of fundus, a good geometry of the wrap, and to assure that the stomach is not twisted. 6. Create a loose and short wrap, approximately 2–3 cm in length.

1.7

Pitfalls & Ways to Avoid

1. A pneumothorax can be created when dissection is performed above the crus in the mediastinum. Dissection should therefore not be extended into the mediastinum. 2. To avoid creating tight wrap, a bougie may be placed at the lower esophagus [7]. 3. Circumferential phrenoesophageal dissection and extensive esophageal mobilization should be avoided.

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It was reported that the incidence of postoperative wrap herniation and need for reoperation increased [8].

References 1. Czinn SJ, Blanchard S.  Gastroesophageal reflux disease in neonates and infants. Pediatr Drugs. 2013;15(1):19–27. https://doi. org/10.1007/s40272-­012-­0004-­2. 2. Wakeman DS, Wilson NA, Warner BW.  Current status of surgical management of gastroesophageal reflux in children. Curr Opin Pediatr. 2016;28(3):356–62. https://doi.org/10.1097/ MOP.0000000000000341. 3. Mauritz FA, Van Herwaarden-Lindeboom MYA, Stomp W, et  al. The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review. J Gastrointest Surg. 2011;15:1872–8. https://doi.org/10.1007/s11605-­011-­1644-­1. 4. Davies I, Burman-Roy S, Murphy MS. Gastro-oesophageal reflux disease in children: NICE guidance. BMJ. 2015;350:g7703. https:// doi.org/10.1136/bmj.g7703. 5. Muensterer OJ, Perger L, Hansen EN, Lacher M, Harmon CM.  Single-incision pediatric endosurgical nissen fundoplication. J Laparoendosc Adv Surg Tech Part A. 2011;21:641–5. https://doi. org/10.1089/lap.2010.0524. 6. Bansal S, Rothenberg SS. Evaluation of laparoscopic management of recurrent gastroesophageal reflux disease and hiatal hernia: long term results and evaluation of changing trends. J Pediatr Surg. 2014;49:72–6. https://doi.org/10.1016/j.jpedsurg.2013.09.035. 7. Daniel Ostlie BJ, Miller KA, Holcomb GW III.  Effective Nissen fundoplication length and bougie diameter size in young children undergoing laparoscopic nissen fundoplication. J Pediatr Surg. 2002;37(12):1664–6. https://doi.org/10.1053/jpsu.2002.36685. 8. St Peter SD, Barnhart DC, Ostlie DJ, et  al. Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr Surg. 2011;46:163–8. https:// doi.org/10.1016/j.jpedsurg.2010.09.081.

2

Laparoscopic Toupet Fundoplication Yew-Wei Tan, Illya Martynov, Martin Lacher, and Amulya K. Saxena

2.1

Indications for Laparoscopic Approach to Toupet Fundoplication

It is important to bear in mind that the aims of any anti-reflux surgery are: 1. to allow passage of food and clearance of esophageal content 2. prevent gastroesophageal reflux (GER) 3. permit incidental eructation/belching Indications: • Severe GER and its complications (e.g. recurrent chest infection, failure to thrive esophagitis and associated bleeding, stricture, and Barrett’s esophagus). • GER associated with esophageal dysmotility Outcome studies in children comparing partial (Toupet fundoplication) and complete (Nissen fundoplication) wrap have not demonstrated benefit of one over another [1], although adult literature suggests that a partial wrap is associated with less dysphagia with equal therapeutic effects, compared to complete wrap [2]. Short term outcomes associated with Toupet fundoplication appeared to fulfill its expecSupplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_2. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. Y.-W. Tan · A. K. Saxena (*) Department of Pediatric Surgery, Chelsea Children’s Hospital, Chelsea and Westminster NHS Foundation Trust, Imperial College London, London, UK e-mail: [email protected] I. Martynov · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany

tation in reducing dysphagia, particularly in esophageal dysmotility [3–5].

2.2

Preoperative Workup and Considerations

Contrast swallow is useful for definition of the anatomy including hiatal hernia, esophageal stricture, and presence of malrotation. To a lesser extent, functional assessment for gastroesophageal reflux and gastric emptying may be appreciated through radiological assessment. In children where swallowing dysfunction is suspected, a video fluoroscopy combined with speech and language therapy assessment could determine the need for combined gastrostomy placement with the fundoplication. 24-hour pH/impedance study enables quantification of the reflux, and help correlate symptoms to reflux episodes. This is usually treated with or without anti-acid medications based on specific clinical question to be answered. Esophagogastroduodenoscopy allows evaluation of esophageal inflammatory changes and confirming the presence of stricture that may warrant dilatation. A pH/impedance probe may be inserted at the same time. If significant esophageal stricture secondary to GER is present, it should be dilated prior to the planned fundoplication. Preoperative consent process should include a discussion of possible complications and adverse events such as risk of esophageal or gastric perforation, transient dysphagia, wrap failure and migration, gastric distension, and re-do surgery.

2.3

Anesthetic Considerations

The patient’s nutritional state should be optimal at the time of surgery, which may be improved with a period of pre-­ operative jejunal feeding in some cases. The pulmonary function should be adequately optimized with the help of respiratory physicians and chest physiotherapy. Many of the

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patients with GER have significant comorbidity and may require postoperative physiological support in an intensive therapy unit. Preoperative enema may help reduce colonic dilatation that could render difficulties during laparoscopy. Patients should be appropriately fasted for general anesthesia. Nitrous oxide should be avoided to prevent bowel dilatation. Following induction of anesthesia, an appropriately sized large bore nasogastric tube is inserted orally passed the gastroesophageal junction, into the stomach. This helps to decompress the stomach in case it is dilated during induction of anesthesia. A single dose of broad spectrum antibiotics is given on induction.

2.4

Operative Technique

and adolescents it is preferred to use the supine split-leg position (French psoition). Venous access is preferred in the upper extremities for this procedure.

2.4.3 Trocar Placement 2.4.4 Operative Milestones Following the umbilical port insertion and CO2 pneumoperitoneum with pressure ranging from 8–12 mmHg depending on patient’s age and size, the right port is placed and the left lobe of the liver is retracted to expose the hiatus (Fig. 2.2).

2.4.1 Equipment • Scope of 5 mm size and 30-degree angle of view • Choice of 4 or 5 ports (5 mm) [6] • Liver retraction can be achieved with either Nathanson retractor, an epigastric port, teethed gasper tenting the left lobe of the liver, or a fan (‘fingers’) retractor • Monopolar hook diathermy • Bipolar, sealing device, or ultrasonic (e.g. Harmonic) dissector, ideally with a curved tip • Non-absorbable sutures on ski-needle • An umbilical-cord tape for anterior or lateral esophageal retraction

2.4.2 Positioning The patients are positioned towards the bottom end of the operating table. In case of infants and toddlers the legs are folded at the level of the knees (Fig. 2.1). In older children

Fig. 2.1  The infant/toddler patient is positioned towards the bottom end of the operating table. The surgeon is positioned in the middle of the table with the cameraman assistant towards the left of the surgeon and the scrub nurse towards the right hand side of the surgeon. The screens are placed directly in the line of vision of the surgeon

Legend Work port Optic port

Fig. 2.2  The optic port is placed in the umbilical fold followed by 2 work ports on either sides to form a triangulation pointing towards the region of interest. Accesory ports are placed on the right side slightly crainial to the right work port to aid insertion of intruments for elevation of the liver, and on the left side side slightly caudal to the left work port to insert an umbilical band secured on a grasper to offer traction of the esophagus during the procedure

Legend

Patient

Monitor Surgeon Assistant Scrub nurse

Instrument table

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Milestone 2.1  Hiatal dissection with the creation of a retrocardial retro-esophageal window (Video 2.1 Laparoscopic Toupet Fundoplication). (▸ https://doi.org/10.1007/000-2tv)

Milestone 2.3  The fundal wrap is then brought around the retro-­ cardial window, with assurance of the wrap mobility demonstrated with the ‘shoe-shine’ maneuver

Milestone 2.2  Hiatal repair. An umbilical tape is passed around the mobilized esophagus for anterior retraction. Two non-absorbable braided 2/0 sutures are placed to approximate the diaphragm crura

Milestone 2.4  Three sutures are placed to approximate the fundus with the right esophagus, with the upper-most suture also include the right diaphragmatic pillar. The same is then performed on the left side to complete the 270’ wrap

The zona pellucida within the lesser omentum is divided to define the right border of the esophagus and separating it from the right crus of the diaphragm. Minimal dissection of the esophagus is usually needed to achieve adequate ­circumferential mobilization. The vagus nerve forms an important landmark, whereby a retrocardial retro-esophageal window is created. This window should be sufficiently large enough to accommodate the fundus that is pulled through (Milestone 2.1). At this point, the nasogastric tube is replaced with an appropriate bougie prior to the hiatal repair. An umbilical-­ cord tape is passed from the left subcostal port, to go around the mobilized esophagus for anterior retraction, and held in place with a pair of grasper. Two non-absorbable braided 2/0 sutures are placed to approximate the diaphragmatic crura (Milestone 2.2). One suture on each side of the esophagus is placed to secure it to the right and left diaphragmatic pillars, using 2/0 non-absorbable sutures. This is to avoid possible rotation of the esophagus prior to the fundoplication. The fundus of the stomach can usually be mobilized without dividing the short gastric vessels when Toupet fundoplication is performed. However, in rare cases if tension is encountered, partial division of the upper short gastric vessels within the gastro-splenic ligament may be necessary. The fundal wrap is then brought around the retro-cardial window, with assurance of the wrap mobility demonstrated

with the ‘shoe-shine’ maneuver (Milestone 2.3). This is facilitated by anterior retraction of the esophagus. The wrap is then brought around the retro-cardial window to sit comfortably without tension. Three sutures are placed to approximate the fundus with the right esophagus, with the upper-most suture also include the right diaphragmatic pillar. The same is then performed on the left side with two further sutures to approximate the wrap with the left esophagus over three quarter of the esophageal girth to complete the 270’ wrap. Sutures should be 2/0 non-absorbable braided sutures (Milestone 2.4). Ensure no torsion of the wrap and esophagus, and the intra-esophageal bougie (or the large bore nasogastric tube) is not accidentally sutured-in. An appropriate size nasogastric tube should be left in-situ for postoperative care. The umbilical tape passed around the esophagus is removed (Milestone 2.5).

2.5

Postoperative Care

1. Patient should have a nasogastric tube left in situ for 24–48 h, if no gastrostomy is in place.

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Milestone 2.5  Final check to exclude torsion of the wrap and esophagus. The surgeon reassures that the intra-esophageal bougie (or the large bore nasogastric tube) is not accidentally sutured-in. The umbilical tape passed around the esophagus is removed

2. No oral feeds are given on the day of surgery, and the trial of feed can be considered the next day if the nasogastric output is minimal. 3. Intravenous fluid and drugs should be administered until enteral tolerance is achieved. 4. Once feeds are tolerated, the nasogastric tube is removed.

2.6

Pearls/Tips & Tricks

1. Preoperative colonic emptying with enema or rectal washout reduces the problem of transverse colon compromising the pneumoperitoneum space, especially in a small abdominal cavity. 2. At the start of the procedure, careful division of the phreno-esophageal membrane facilitates crucial visualization of the anatomy i.e. definition of right and left diaphragmatic pillars, and the esophagus, in order to prevent unrecognized esophageal or vagus nerve injury. 3. The tape encircling the esophagus is useful to exaggerate the retro-cardial window when pulled anteriorly, and facilitates an adequate 2–3 cm of intra-abdominal esophagus for the fundoplication wrap when pulled inferiorly. 4. Regarding the suturing of the wrap, two stitches should be used to tack the posterior wrap to the right diaphragmatic pillar, then move on the left side, encircling the fundus on three quarter of its girth.

2.7

Pitfalls & Ways to Avoid

1. Using appropriately size liver retractor is important. When the Nathanson retractor is used, it should be inserted to the left of the falciform ligament, and placed in such a way that the curve should support the entire left lobe of the liver without overzealous retraction, which carries the risk of liver congestion and bleeding. If a

Babcock gasper is used to lift up hepatic left lobe, it is also introduced from the right port, and fixed to the left diaphragmatic pillars. 2. Sufficient mobilization of the esophagus into the abdomen should be achieved so that the wrap is placed around the esophagus and not around the stomach. 3. Care should be taken to identify the vagus nerve and to prevent injury during esophageal mobilization. 4. It is noteworthy that placement cruroplasty sutures needs to be accurate and considered, because vital organs are within the vicinity: the aorta posteriorly, the heart superiorly, and the caudate lobe of the liver on the right, all at risk of being injured with serious consequences. 5. Prior to cruroplasty, an appropriate size bougie or nasogastric tube needs to be positioned in the esophagus to avoid narrowing of the esophagus at the point it cross the diaphragm. Also once the fundoplication is complete and a large bore nasogastric tube is used to calibrate the esophagus, the tube should be mobilized to ensure that no stich is hitched to it. In presence of a hiatus hernia, direct crus approximation or  a modified cruroplasty are preferred otions [7]. However, if a large hiatal defect is present, the use of a patch may be necessary. 6. Variations in anatomy can lead to increased risk of hemorrhage. An aberrant left hepatic artery can sometimes be found within the pars condensa of the lesser omentum in 8–25%. If the vessel is small, its division should have no functional consequence but this could lead to transient rise in transaminases; however if it is large, it could be the dominant hepatic artery therefore should be preserved to prevent partial hepatic ischemia (Video 2.1).

References 1. Glen P, Chassé M, Doyle MA, Nasr A, Fergusson DA. Partial versus complete fundoplication for the correction of pediatric GERD: a systematic review and meta-analysis. PLoS One. 2014;9(11):e112417. 2. Tian ZC, Wang B, Shan CX, Zhang W, Jiang DZ, Qiu M. A meta-­ analysis of randomized controlled trials to compare long-term outcomes of Nissen and Toupet fundoplication for gastroesophageal reflux disease. PLoS One. 2015;10(6):e0127627. 3. Lund RJ, Wetcher GJ, Raiser F, Glaser K, Perdikis G, Gadenstätter M, Katada N, Filipi CJ, Hinder RA.  Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility. J Gastrointest Surg. 1997;1(4):301–8. 4. Heading RC.  Should abnormal oesophageal motility in gastro-­ oesophageal reflux disease (GORD) influence decisions about fundoplication? Gut. 2002;50(5):592–3. 5. Rintala RJ.  Fundoplication in patients with esophageal atresia: patient selection, indications, and outcomes. Front Pediatr. 2017;5:109. 6. Montupet P, Saxena A.  Toupet fundoplication. In: Saxena A, Höllwarth M, editors. Essentials of pediatric endoscopic surgery. Berlin: Springer; 2009. 7. Pavy G, Moldovanu R. A modified Nissen – Toupet procedure for the treatment of gastroesophageal reflux disease and hiatal hernia: how I do it. Jurnalul de Chirurgie. 2011;7:279–94.

3

Laparoscopic Thal Fundoplication Jan H. Gosemann, Illya Martynov, and Martin Lacher

3.1

Indications for Laparoscopic Thal Fundoplication

Symptomatic gastroesophageal reflux disease (GERD) especially in neurologically impaired children remains the main indication for anti-reflux surgery in children. The indications for laparoscopic fundoplication are the same as for the open approach. Laparoscopic Thal fundoplication has previously been reported to be associated with lower rates of postoperative dysphagia, fewer perioperative complications, and better long-term outcomes compared to Nissen fundoplication [1, 2]. However, in a more recent prospective monocentric setting long-term recurrence rates have been described higher than expected after Thal fundoplication [3]. Independent of the surgical technique, the following three operative steps are essential for all anti-reflux procedures [4]: 1. Creation of intraabdominal length of the distal esophagus 2. Narrowing of the diaphragmatic hiatus 3. Fixation of the fundus against/around the distal esophagus with or without additional stiches to the diaphragm

3.2

Preoperative Workup and Considerations

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_3. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. J. H. Gosemann (*) · I. Martynov · M. Lacher Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany e-mail: [email protected]

Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend a detailed history and physical exam in children with typical symptoms of GERD [5].  Alarm signs or failure of medical treatment should implicate further diagnostic steps, including –– esophagogastroscopy with biopsies to diagnose or rule out complications of GERD or other conditions (e.g. eosinophilic esophagitis, infection and Crohn’s disease) –– contrast study of the upper GI tract to detect anatomic abnormalities such as hiatal hernia, gastric outlet obstruction or malrotation [5]. –– 24 h impedance pH monitoring

3.3

Anesthetic Considerations

Preoperative preparation should include an enema to enhance intra-abdominal visualization by sufficiently emptying the colon. Laparoscopic Thal fundoplication is performed under general anesthesia and endotracheal intubation. After decompression of the stomach via nasogastric tube, the tube is removed and an esophageal bougie is inserted, depending on the weight of the child (Table 3.1, [6]). As a rule of thumb, the diameter of the patient’s thumb may also be used to determine the bougie size (Fig. 3.1). If available, perioperative epidural anesthesia may be performed by a dedicated pain service [7]. Table 3.1 Recommended bougie size for esophageal calibration according to patient weight [6] Weight (kg) 2.5–4.0 4.0–5.5 5.5–7.0 7.0–8.5 8.5–10.0 10.0–15.0

Bougie size 20–24 24–28 28–32 32–34 34–36 36–40

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_3

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J. H. Gosemann et al.

Operative technique.

3.4.1 Equipment • 3 × 3-mm trocars or 1 × 5 mm trocar and 1 × 3 mm trocar for the SIPES technique • 5 mm trocar for 30° scope

• 3 or 5 mm atraumatic grasper • 3 or 5 mm atraumatic bowel grasper • 3 or 5 mm hook monopolar cautery (patient needs grounding pad) • 2-0 /3-0 silk suture (ski needle) or 2-0/3-0 polyester suture (hiatus, fundus) • 2-0 polyglycolic acid suture (closure of fascia) • Nathanson liver retractor or triangular liver retractor

3.4.2 Positioning Infants: Supine frog leg-positioning at the end of the table with both arms tucked to the side (Fig. 3.2a). Older children: Supine position with legs placed on abductable leg holders. The hip should be placed over the bending point of the table to allow a hyperextension just above the hip, which will facilitate better range of movement of the instruments (Fig. 3.2b). The surgeon stands at the end of the table/between the patient’s legs. The first assistant is positioned to the surgeon’s left side (Fig. 3.3). Fig. 3.1  Determination of bougie size Fig. 3.2  Positioning of the patient (a infant, b older child)

Fig. 3.3  Positioning of surgeons, scrub nurses and monitor

a

b

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse Instrument table

3  Laparoscopic Thal Fundoplication

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3.4.3 Trocar Placement A 5 mm trocar is placed in the umbilicus in an open technique (Fig. 3.4). The capnoperitoneum is insufflated using a pressure of 6–10 mmHg and a flow of 4–6 l/min depending on the age of the child. Liver retraction: See below. Left/right hand: A 3 or 5 mm trocar is inserted in right and left subcostal position. Second optic trocar: To focus on the operative field, another 5 mm trocar is placed halfway between xiphoid and umbilicus. The umbilical trocar will subsequently be used for retraction of the stomach after placement of a vessel loop around the esophagus.

and umbilicus after placement of the other working trocars. An atraumatic grasper is inserted via the umbilical trocar and is used to put traction on the distal esophagus and fundus. This maneuver allows a sufficient exposure of hepatogastric and phrenoesophageal ligament. Subsequently, division of hepatogastric and phrenoesophageal ligament is facilitated with the monopolar hook and

3.4.4 Operative Milestones For liver retraction either a triangular liver retractor is introduced via a 5  mm trocar in the right costal margin (Fig. 3.5a) or a Nathanson liver retractor is inserted via a subxiphoidal incision (Fig.  3.5b) (Milestone 3.1). The camera is changed to the trocar halfway between xiphoid

Milestone 3.1  Liver retraction. Either a triangular liver retractor is introduced via a 5 mm trocar in the right costal margin or a Nathanson liver retractor is inserted via subxiphoidal incision. This allows a sufficient exposure of hepatogastric and phrenoesophageal ligament (Video  3.1 Fundo Thal GOSEMANN MARTYNOV LACHER V2). (▸ https://doi.org/10.1007/000-2tw)

Legend Working trocar Endoscope trocar Liver retraction

Milestone 3.2  Division of hepatogastric and phrenoesophageal ligament is facilitated with the monopolar hook and blunt dissection (Milestone 3.2). Care has to be taken not to injure the anterior vagus nerve

Fig. 3.4  Trocar placement

Fig. 3.5  Liver retractor (a triangular, b Nathanson)

a

b

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Milestone 3.3  Definition of the hiatus. Monopolar and blunt dissection is used to identify left and right crus and to define the hiatus

J. H. Gosemann et al.

Milestone 3.5  Narrowing of the hiatus. Stiches are performed from the right to the left side, using either silk or polyester suture (2-0/3-0). The uppermost suture may include the posterior esophageal wall. During the plastic reconstruction of the hiatus, the esophageal bougie is placed into the stomach to avoid narrowing of the esophagus

Milestone 3.4  Placement of a vessel loop around the esophagus. After creation of a window behind the esophagus, a vessel loop is placed around the esophagus for retraction. Dissection of the posterior wall and the hiatus can now be completed Milestone 3.6  Thal fundoplication—first row of stiches. The first row of stiches is placed between the anterior wall of the fundus and the distal esophagus halfway along its intra-abdominal length. Care has to be taken to avoid injury to the anterior vagus nerve

blunt dissection (Milestone 3.2). Care has to be taken not to injure the anterior vagus nerve or an aberrant left hepatic artery. Division of the short gastric vessels prevents traction on the spleen while moving the fundus. Monopolar and blunt dissection is further used to identify left and right crus and to define the hiatus (Milestone 3.3). After creation of a window behind the esophagus, a vessel loop is placed around the esophagus for retraction. Dissection of the posterior wall and the hiatus can now be completed (Milestone 3.4) to bring the distal esophagus into the abdominal cavity. The second step of every anti-reflux procedure comprises narrowing of the hiatus (Milestone 3.5). These sutures are placed from the left to the right side, using either silk or polyester suture (2-0/3-0). The uppermost suture may include the posterior esophageal wall to secure the intra-abdominal position of the distal esophagus. During the reconstruction of the hiatus, the esophageal

bougie is left in situ to avoid narrowing of the esophagus. Afterwards, the bougie can be removed. The Thal fundoplication is characterized by suturing the anterior fundus in two layers: The first row of stiches is placed between the anterior wall of the fundus and the distal esophagus halfway along its intra-abdominal length (Milestone 3.6). Again, care has to be taken to avoid injury to the anterior vagus nerve. The fundoplication is completed by a second row of stiches between the anterior wall of the fundus, the proximal part of the intra-abdominal esophagus and the diaphragmatic rim/hiatus/crura (Milestone 3.7). With these stiches the fundus is fixed around the distal esophagus and the diaphragm, creating an appropriate angle of His and ensuring an intra-abdominal position of the distal esophagus. The instruments are removed, and the abdomen is allowed to desufflate. Adhesive Strips (Steri-Strips™) or skin glue is all that are required for skin closure.

3  Laparoscopic Thal Fundoplication

17

3.7

Milestone 3.7  Thal fundoplication—second row of stiches. The fundoplication is completed by a second row of stiches between the anterior wall of the fundus, the proximal part of the intra-abdominal esophagus and the diaphragmatic rim/hiatus. With these stiches the fundus is fixed around the distal esophagus and the diaphragm, creating a his angle and ensuring an intra-abdominal position of the distal esophagus

3.5

Postoperative Care

The patient is allowed to start oral feeds (milk, formula) immediately after surgery. No food restriction or special diets are required. Once the child is tolerating full enteral feeds it can be discharged home. Postoperative complications include retching and dysphagia as well as recurrent GERD.

3.6

Pearls/Tips & Tricks

1. Preoperative preparation should include an enema to enhance intra-abdominal visualization by sufficiently emptying the colon. 2. A sufficient liver retraction is essential for a good exposure of the operative field. 3. The instrument inserted via the umbilical trocar is constantly used for maneuvering the stomach to expose the operative field. 4. An esophageal bougie of appropriate size prevents narrowing of the esophagus. 5. The vessel loop placed around the esophagus for esophageal retraction facilitates dissection of the posterior esophagus and the narrowing stiches of the hiatus.

Pitfalls & Ways to Avoid

1. Injury to the anterior or posterior vagus nerve should be avoided. 2. In very young infants the liver can bleed easily and make visualization difficult. 3. When dividing the short gastric vessels an injury to the splenic capsule especially at the upper pole can cause bleeding and make visualization difficult. 4. The surgeon should be aware of anatomic variants such as an aberrant left hepatic artery. 5. When suturing the wrap a significant amount of tissue should be taken as the wrap otherwise may disrupt easily.

References 1. Vanderzee DC, Rövekamp MH, Tergunne A, Bax N.  Surgical-­ treatment of reflux esophagitis  - Nissen versus Thal procedure. Pediatr Surg Int. 1994;9:334–7. 2. Kubiak R, Andrews J, Grant HW.  Long-term outcome of laparoscopic Nissen fundoplication compared with laparoscopic Thal fundoplication in children a prospective, randomized study. Ann Surg. 2011;253:44–9. 3. Mauritz FA, van Herwaarden-Lindeboom MYA, Zwaveling S, Houwen RHJ, Siersema PD, van der Zee DC.  Laparoscopic Thal fundoplication in children a prospective 10- to 15-year follow-up study. Ann Surg. 2014;259:388–93. 4. Esposito C, Montupet P, van Der Zee D, Settimi A, Paye-Jaouen A, Centonze A, et al. Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease. Surg Endosc. 2006;20:855–8. 5. Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, et  al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the north American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018;66:516–54. 6. Ostlie DJ, Miller KA, Holcomb GW.  Effective Nissen fundoplication length and bougie diameter size in young children undergoing laparoscopic Nissen fundoplication. J Pediatr Surg. 2002;37:1664–6. 7. McNeely JK, Farber NE, Rusy LM, Hoffman GM. Epidural analgesia improves outcome following pediatric fundoplication. A retrospective analysis. Reg Anesth. 1997;22:16–23.

4

Laparoscopic Heller Myotomy Lea Sibylle Waldron and Oliver J. Muensterer

4.1

Evidence on Outcome for Laparoscopic Heller Myotomy

Different surgical approaches for achalasia are available: open myotomy, thoracoscopic myotomy, laparoscopic myotomy plus fundoplication, endoscopic peroral myotomy [1] and more recently, robotic myotomy. Heller myotomy is most commonly performed using  a laparoscopic approach, as it has better short-term outcomes and similar long-term outcomes compared to the open procedure [2, 3]. In a comparative study to the thoracoscopic approach, Pattie et  al. found that the laparoscopic technique resulted in  a shorter hospital stay, a better result in terms of resolution of dysphagia and reflux, as well as better postoperative results in terms of reflux control [4]. In contrast, the thoracoscopic and endoscopic peroral myotomies do not allow an antireflux prophylaxis [5]. Robotic myotomy seems promising, with potentially less esophagal perforation and less conversion to open surgery. However, long term results are not yet available and in smaller children, instrument size may be a limiting factor [6]. Therefore, once achalasia is diagnosed in a child, we suggest to try pneumatic dilation in three consecutive settings. If dilation is not successful it is advisable to apply a laparoscopic heller myotomy, particularly in patients of young age and low surgical risk factors. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_4. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. L. S. Waldron (*) Department of Pediatric Surgery, University Medical Center, Mainz, Germany O. J. Muensterer Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

4.2

Preoperative Workup and Considerations

The main clinical symptoms of achalasia are dysphagia combined with weight loss, regurgitation, recurrent bronchopulmonary infection, chest pain, hiccups and cough [7]. In Patients who show clinical symptoms of achalasia, a diagnostic algorithm of endoscopy, upper gastrointestinal contrast study, and high resolution manometry is warranted to confirm the diagnosis. Three stages of achalasia are described in literature. A Hypermotile achalasia = Vigorous Achalasie (Type 1), B—Hypomotile achalasia (Type 2), C—Amotile achalasia (Type 3). It is important to take into consideration that the extent of the esophagographic findings do not necessarily correlate with symptoms.

4.3

Anesthetic Considerations

Heller myotomy and additional hemifundoplication is typically preformed under general endotracheal anaesthesia. A naso- or orogastric-tube is placed to decompress the stomach, or alternatively, simultaneous intraoperative esophagogastroscopy can be performed. Periooperativly, a single antibiotic dose is given for prophylaxis. Although intraopertive bleeding is rare, having blood and two peripheral intravenous lines available is advisable.

4.4

Operative Technique Equipment

• 3–5 mm 30° Laparoscope • 3–5 mm trocars (the authors prefer to place a single-port trocar in the umbilicus) • 3 mm trocars as needed • 3–5 mm instruments and trocars • 3–5 mm Maryland dissector • 3–5 mm atraumatic grasper

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_4

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L. S. Waldron and O. J. Muensterer

Fig. 4.1  Positioning of patient, surgeons and monitors

Legend

Patient

Monitor Surgeon Assistant Scrub nurse

Instrument table

• • • • • • •

3–5 mm needle holder 3–5 mm Metzenbaum scissors 3–5 mm hook monopolar cautery (grounding pad) 3–5 mm Laparoscopic liver retractor 3–5 mm monopolar hook cautery 6–10 mm endoscope 2–0 silk sutures on a skin needle

4.5

Trocar Placement

The umbilical trocar (in our case a single-port trocar) is placed in the umbilicus via a longitudinal incision. A 3 mm 30° optic is introduced through the umbilical port. After insufflating the capnoperitoneum and under vision, one 3 mm trocar is placed in the epigastric area and one 3 mm trocar is placed in the left upper abdominal quadrant (Fig. 4.2).

4.7

Working trocar Endoscope trocar

Positioning

The patient is positioned supine with arms tucked to the sides and abducted lower extremities. The surgeon stands at the foot end of the bed, the monitor is placed at the head of the patient in-line with the surgeon and patient. The assistant is on the right side and the scrub nurse on the left of the patient (Fig. 4.1). The abdomen is prepped and draped from the nipples to the symphysis.

4.6

Legend

Operative Milestones

After placing the trocars, the liver is suspended upwards towards the abdominal wall using a laparoscopic liver retractor (Video 4.1). We position a concomitant endoscope oro-

Fig. 4.2  Positioning of the trocars

pharyngeally at the esophagogastric junction as a visual reference, since in our opinion, the transillumination helps with identification of the muscle fibers during the dissection (Milestone 4.1). After grasping the stomach and retracting it to the superior left side of the patient the  gastro-hepatic ligament and gastrophrenic membrane are opened using a monopolar hook cautery to gain access to the esophagus (Milestone 4.2). The vagal nerve as well as the vessels are identified and carefully mobilized from the esophagus using a Maryland dissector and preserved throughout the operation (Milestone 4.3). A blunt division of the longitudinal muscular fibre is carried out from distal (stomach) to proximal (esophagus) using a monopolar hook cautery. We generally carry out the d­ issection approximately 5 cm distal and 5 cm proximal to the esophagogastric junction through the seromuscular muscular layers, creating a generous, adequate myotomy and thereby minimizing the chance of recurrence (Milestone 4.4).

4  Laparoscopic Heller Myotomy

21

The muscular margins are then sutured to the right and left crus using simple 2-0 silk sutures, retracting the myotomy open. Subsequently, a (180° anterior) Thal—fundoplication is created by folding the fundus over the myotomy and attaching it with 2-0 silk interrupted sutures to the right crus, the anterior hiatus and the left crus. Finally, the completed Heller myotomy and fundoplication is checked using the endoscope and gas insufflation (Milestone 4.5).

4.8

Postoperative Care

The patient is transferred to a peripheral ward and a nasogastric tube is left and drained to gravity. The patient is allowed clear liquids after 24 h. Two days after surgery, an esophagogram is preformed to evaluate the emptying of the esophagus and to rule out any leakage. If the scan does not show comMilestone 4.1 Laparoscopic liver retractor and concomitant plications, the patient is given a soft diet and discharged from endoscope (Video 4.1 Laparoscopic Heller Myotomy).­hospital on full enteral nutrition. We tend to prescribe a no-­ ­ (▸ https://doi.org/10.1007/000-2tx) chunk diet initially and allow normal eating and normal

Milestone 4.2  Gastro-hepatic ligament and gastrophrenic membrane Milestone 4.4 Heller myotomy performed approximately 5 cm proximal (a) and 5 cm distal (b) to the gastroesophageal junction

a

Milestone 4.3  Vagal nerve and vessels are preserved

b

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L. S. Waldron and O. J. Muensterer

Milestone 4.5  The borders of the myotomy are sutured to the crura (a) and the myotomy is then covered with a (180° anterior) Thal— fundoplication (b)

a

activitiy after 4  weeks. Clinical follow up is performed at yearly intervals to make sure the patient does not suffer recurrence.

4.9

Pearls/Tips & Tricks

1. Using a single-port trocar allows the surgeon to place both the optic and the liver retractor through the navel and limit additional trocar sites. 2. We create a long myotomy, at least 5  cm proximal and 5  cm distal of the esophagogastral junction, using the horizontal muscle fibers of the antrum as the reference point that the gastroenteric tract is reached, making sure not to leave any remnant muscle fibers and thereby to avoid a recurrence. 3. Intraoperative endoscopy helps to delineate the muscle fibers by transillumination. At the same time, perforation can be ruled out from endoluminally and by insufflating gas.

4.10 Pitfalls & Ways to Avoid 1. Mucosal injury and leakage is one of the most serious complications during myotomy especially if monopolar energy is used for the dissection of the muscular layer.

b

The monopolar energy current  should be  dosed carefully to prevent thermal injury to the mucosa. Therefore, identification and dissection of the muscluar tissue is important. If a leak occurs it can be repaired with e.g. Monocryl 5.0. 2. The vagus nerve runs along the operative field. It is important to identify and preserve it during the procedure.

References 1. Caldaro T, Familiari P, et al. Treatment of esophageal achalasia in children: today and tomorrow. J Pediatr Surg. 2015;50:726–30. 2. Allaix ME, Patti MG. Heller myotomy for achalasia. From the open to the laparoscopic approach. World J Surg. 2015;39:1603–7. 3. Askegard-Giesmann JR, Fau GJ, et  al. Minimally invasive Heller’s myotomy in children: safe and effective. J Pediatr Surg. 2009;44:909–11. 4. Hunter JG, Fau TT, Branum GD, et al. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg. 1997;225:655–65. 5. Rothenberg SS, Da Fau P, et al. Evaluation of minimally invasive approaches to achalasia in children. J Pediatr Surg. 2001;36:808–10. 6. Ballouhey Q, Dib N, Binet A, et al. How robotic-assisted surgery can decrease the risk of mucosal tear during Heller myotomy procedure? J Robotic Surg. 2017;11:255–8. 7. Kotilea K, Mahler T, Bontems P, et  al. Management of esophageal motility disorders in children: a review. Acta Gastroent Belg. 2018;81:295–304.

5

Foregut Duplication or Esophageal Duplication Yury Kozlov, Alexander Razumovsky, and Alexander Smirnov

5.1

Indications for Thoracoscopic Approach to Esophageal Duplication

Most thoracic esophageal duplication cysts are located on the right side. In rare cases they can communicate with the esophageal lumen. Symptoms of this malformation develop due to a mass effect with compression of the lung and airway. The esophageal duplication of the thoracic segment can look similar to a mediastinal mass such as neuroblastoma. In older patients esophageal duplication can cause dysphagia and hemorrhage as a result of the presence of ectopic mucosa, which is observed in half of such patients [1]. Communication with the spine/spinal canal occurs in 20% of children [2]. One quarter of patients have thoracoabdominal forms. Most of esophageal duplications do not cause symptoms and are an incidental finding on prenatal ultrasound, routine clinical examinations after birth, surgical interventions or autopsy. Asymptomatic children often have isolated duplications [3]. However, because of their secretory nature or presence of ectopic tissue they can sometimes lead to life-threatening conditions such as respiratory distress, esophageal obstruc-

tion, bleeding and inflammation, removal of the duplication is performed urgently. In these cases early surgical excision is always recommended to prevent a symptomatic course of the disease. Currently, most thoracic duplications can be removed thoracoscopically [4].

5.2

Preoperative Workup and Considerations

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_5. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App.

Esophageal duplication may be seen on a chest X-ray. CT and MRI can detect spherical masses in the thoracic cavity approximately 2–8 cm in size and often have a hyperechoic inner mucosal layer and a hypoechoic outer muscular layer [5]. MRI is the preferred method in children, as it doesn’t use radiation, provides reliable data on the blood supply of duplication without the need for intravenous contrast and detailed visualization of structural layers of the cyst. Furthermore, MRI does not only show the duplication cysts but also associated defects like spinal anomalies. SPECT (single-photon emission computed tomography) plays an increasing role in the detection of thoracoabdominal duplications and recurrence of the disease. Before the operation, pulmonary function should be evaluated. A blood gas analysis should be obtained to exclude respiratory acidosis as a result of compression of the lung and trachea.

Y. Kozlov (*) Department of Pediatric Surgery, Children’s Hospital, Irkutsk, Russia

5.3

Department of Pediatric Surgery, State Medical University, Irkutsk, Russia A. Razumovsky Department of Pediatric Surgery, Filatov Children’s Hospital, Moscow, Russia Department of Pediatric Surgery, Pirogov Russian National Research Medical University, Moscow, Russia A. Smirnov Department of Endoscopy, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia

Anesthetic Considerations

Thoracoscopic excision of esophageal duplication is performed under general endotracheal anesthesia. For good exposure of an esophageal duplication, the lung should be collapsed. This can be accomplished by single-lung ventilation via a double lumen endotracheal tube or by bipulmonary ventilation using endobronchial blockers in older children. In small children bipulmonary lung ventilation is used. At least two peripheral intravenous cannulas should be available

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_5

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for resuscitation in case of bleeding. A nasogastric tube should be inserted to facilitate identification of the esophagus.

5.4

5.4.3 Trocar Placement

Operative Technique

5.4.1 Equipment • • • • • • • •

duplications in the left hemithorax, the patient is placed on the right side.

3 or 5 mm 30° laparoscope 3 mm instruments and trocars 3 mm Kelly dissector 3 mm atraumatic “duckbill” grasper 3 mm needle holder 3 mm Metzenbaum scissors 3 mm hook monopolar cautery 5–0 monofilament polydiaxone sutures (for the suturing of the esophagus when is it necessary)

For thoracoscopic treatment of esophageal duplication, the standard esophageal position of ports is used. The first trocar is placed in the sixth intercostal space, posterior axillary line. After a penetration of the pleura a capnothorax is established. In small children low settings are used (pressure 4–6 mmHg; flow 0.5–1 l/min). The other two ports are placed in the right hemithorax under thoracoscopic control in the midaxillary line. For better ergonomics the instrumental ports are inserted on the sides of the optical trocar to form a 60-degree-­ manipulation angle between the instruments. Usually they are placed one intercostal space above and below the telescope (Fig. 5.2).

5.4.2 Positioning

5.4.4 Operative Milestones

Duplication cysts are most often located on the right side. The child is placed in a modified prone position with the right side elevated 30–45 degrees and with a towel roll under the chest to enlarge of intercostal space. The right arm should be positioned towards the head. The surgeon stands at the left side of the operating table facing the patient. The monitor is located on the right side of the operating table in-line with the surgeon and patient. The assistant stands to the left side of the surgeon, the scrub nurse on the other side of the operating table facing the surgeon (Fig. 5.1). A second monitor can be placed on the left side for the scrub nurse. In case of

After inspection of the thoracic cavity the esophageal duplication cyst is visualized (Milestone 5.1). A puncture of the esophageal cyst is performed and the mucus emptied (Milestone 5.2). The parietal pleura overlying the duplication is grasped and incised using a monopolar hook. Gradually, using a Kelly dissector and hook, the duplication is released from the surrounding tissues. Special care is taken when handling/dissecting around the aorta, azygos vein, vagus nerve, sympathetic trunk and thoracic lymphatic duct. At the base of the cyst, a delicate dissection from the ­esophagus is performed with coagulation of feeding vessels

Fig. 5.1  Positioning of patient, surgeons and monitors

Legend

Patient

Monitor Surgeon Assistant Scrub nurse Instrument table

5  Foregut Duplication or Esophageal Duplication

25

ST ED

Legend Working trocar Endoscope trocar VN

Fig. 5.2  Positioning of the trocars

Milestone 5.3  Dissection of the esophageal duplication from surrounding structures: ED—esophageal duplication, VN—vagus nerve, ST—sympathetic trunk

ED

RL

Milestone 5.1  Intraoperative view on the esophageal duplication cyst: ED—esophageal duplication; RL—right lung (Video 5.1 Kniga-3_mpeg4.mp4). (▸ https://doi.org/10.1007/000-2ty)

Needle

ED

Milestone 5.4  Final view—posterior mediastinum after removing of an esophageal duplication

The specimen can be extracted through a slightly enlarged trocar site. If there is any question of infection the specimen should be retrieved in a bag to prevent contamination of the pleural cavity or port sites and extracted through an extended port-incision. After hemostasis is accomplished the intercostal spaces are infiltrated by bupivacaine. Finally, the air is removed from the pleural cavity and a pleural tube is placed through the lower trocar site.

5.5 Milestone 5.2  Puncture of an esophageal cyst and emptying of mucus: ED—esophageal duplication

(Milestone 5.3). Dissection from the esophageal wall should be carried out carefully. As these forms of foregut duplications usually do not communicate with the esophageal lumen, they can be removed without damage to the mucosa (Milestone 5.4).

Postoperative Care

In most cases the child is extubated at the end of operation. A chest X-Ray is performed in the recovery room. The chest tube is left in place as long as there is exudation. Pain is usually controlled with an intermittent intravenous narcotic during the first 12–24 h and patients are switched to oral pain medication. The nasogastric tube is removed. Oral feeding is started immediately. The patients are discharged as soon as they are comfortable on oral pain medication.

26

5.6

Y. Kozlov et al.

Pearls/Tips & Tricks

1. The most difficult form is thoracoabdominal duplication. For these patients it is better to use a simultaneous thoracoscopic and laparoscopic approach [6]. 2. In case of communication with the esophagus, it is necessary to cover the esophageal wall with a single layer of sutures. 3. Vessel sealing devices such as 5  mm BiClamp® or LigaSure™ can be used in cases of focal inflammation and bleeding

5.7

Pitfalls & Ways to Avoid

1. Thoracic lymphatic duct injury—This is a rare postoperative complication results from damage to the lymphatic duct. The treatment usually consists of chest tube insertion and nothing by mouth or a fat-free feeding formula to decrease chyle production. If the chylothorax does not resolve, octreotide is prescribed. Surgical intervention remains the last option. 2. Tracheal injury—MIS is associated with a risk of tracheal injury. It can be treated by full-thickness closure of tracheal laceration using monofilament polydiaxone sutures. 3. Multiple alimentary tract duplications—It is important to look for synchronous abdominal duplication which is

prevalent in 25% of cases. In these children it is necessary to perform abdominal ultrasound, MRI or CT and apply laparoscopy for treatment of associated malformations. 4 . Сases with an associated spinal malformation— Communication with the spinal canal occurrs in 20% of patients. When such a communication is suspected, it is necessary to perform an MRI myelography. Also, the surgical operation should be planned together with the neurosurgeon (Video 5.1).

References 1. Holcomb G, Keckler S. Alimentary tract duplications. In: Holcomb G, Murphy J, Ostlie D, editors. Ashcraft’s pediatric surgery. 6th ed. Philadelphia, PA: Elsevier; 2014. p. 539–47. 2. Holcomb GW III, Gheissari A, O’Neil JA. Surgical management of alimentary tract duplications. Ann Surg. 1989;209:167–74. 3. Mayer JP, Bettolli M.  Alimentary tract duplications in newborns and children: diagnostic aspects and the role of laparoscopic treatment. World J Gastroenterol. 2014;20:14263–71. 4. Perger L, Azzie G, Watch L, Weinsheimer R.  Two cases of thoracoscopic resection of esophageal duplication in children. J Laparoendosc Adv Surg Tech A. 2006;16:418–21. 5. Trappey A, Hirose S. Esophageal duplication and congenital esophageal stenosis. Semin Pedaitr Surg. 2017;26:78–86. 6. Martinez-Ferro M, Laje P, Piaggio L.  Combined thoraco-­ laparoscopy for trans-diaphragmatic thoraco-abdominal enteric duplications. J Pediatr Surg. 2005;40:e37–40.

6

Nutritional Access Procedures Stephan Rohleder and Takafumi Kawano

6.1

Indications for Endoscopic and Laparoscopic Assisted Approach to Nutritional Access

For short durations of inadequate oral food intake, a nasogastric tube can be used for enteral feeding. According to the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines indications for artificial enteral nutrition access include scenarios in which (1) oral feedings are no longer possible (2) oral intake for an expected duration of more than 2–3 weeks is inadequate [1, 2]. In patients with a significant risk of aspiration the guidelines suggest favoring gastrojejunal tubes (GJ tube) over gastric feeding devices. Different types of enteral feeding devices are shown in Fig. 6.1. Gastrostomy placement is not recommended for patients with uncorrected bleeding disorders, severe ascites, or peritonitis. In case of pharyngeal or esophageal obstruction laparoscopy is used.

6.2

Preoperative Workup and Considerations

Symptoms of severe gastro-esophageal reflux disease (GERD) or upper gastrointestinal dysmotility should be ruled out. Gastrostomy placement may worsen symptoms if Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_6. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. S. Rohleder (*) Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany e-mail: [email protected] T. Kawano Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan e-mail: [email protected]

GERD is present [3, 4]. A combined anti-reflux procedure such as fundoplication and gastrostomy placement may be an option in the case of GERD.  An upper gastrointestinal (UGI) contrast study provides valuable information of delayed gastric emptying. However, detection of reflux on UGI series has a low correlation with reflux symptoms. Therefore preoperative UGI contrast studies are not routinely required before laparoscopic gastrostomy placement because of low positive predictive value for GERD and the low incidence of malrotation (less than 1%) [5]. No specific bowel preparation is required.

6.3

Anesthetic Considerations

Laparoscopic assisted gastrostomy is typically performed under general endotracheal anesthesia. Often nutritional access procedures are necessary in infants or small children that have associated anomalies, therefore these cases should be performed by experienced pediatric anesthesiologists. Intraoperative bleeding is extremely rare and having blood available is usually not necessary. At least 1 peripheral intravenous catheter should be available and hypothermia should be avoided. Single-shot antimicrobial prophylaxis with ampicillin/sulbactam or cefalozolin is advisable.

6.4

Operative Technique

6.4.1 Equipment • 3 2-0 braided polyglactin sutures with ½ 37  mm round needle (to suspend the corpus transabdominally), alternatively: 4 T-bar fixators or lasso suture retriever • 1 18 G access needle and 1 J-tip guidewire (to use with step step-dilator) • 1 18 Fr step-dilator, alternatively: peel-away sheath and trocar

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_6

27

28 Fig. 6.1  Nutritional gastric and jejunal access devices (a) Gastric button 14 Fr. 2.5 cm, (b) Gastric tube 14 Fr, (c) Gastric-Jejunal Button 14 Fr. 1.5/22 cm, (d) Gastric-Jejunal Tube 14 Fr 30 cm, (e) Jejunal Tube 14 Fr

S. Rohleder and T. Kawano

a

b

Gastric button 14 Fr. 2.5cm

c

Gastric tube 14 Fr.

d

Gastric-Jejunal Button 14 Fr. 1.5/22cm

Gastric-Jejunal Tube 14 Fr 30cm

e

Jejunal Tube 14 Fr.

• 1 stoma measuring device (if primary button placement is targeted) • 12 Fr (small infants) or 14 Fr (pre-school and school age children) enteral feeding device for laparoscopic (assisted) procedure: • 2 or 3 mm instruments and trocars • 3 mm 30° laparoscope • 1 2 or 3 mm atraumatic laparoscopic grasper • 1 2 or 3 mm needle holder, 1 (Mayo-Hegar) needle holder

for endoscopic procedure: • 1 5 or 6 mm flexible endoscope

6.4.2 Positioning Children are placed in a supine position at the lower end of the operating table with arms extended sideways. The patient should be secured by tape to the bed to allow safe

6  Nutritional Access Procedures

29

reverse Trendelenburg positioning during the procedure if necessary. For school age children the surgeon stands on the right side of the patient, the assistant on the left side. The scrub nurse stands to the left of the assistant. The monitor is positioned at the head of the bed in-line with surgeon. The abdomen is prepped and draped from the nipples to the symphysis. The costal margins and preferred gastrostomy site are marked prior to insufflation (Milestone 6.1). The monitor is at the lower end of the table (Fig. 6.2). Small infants can also be placed in a supine frog leg-­ position at the foot end of the table (Fig. 6.3). In this scenario the surgeon stands at the foot end of the table, the assistant stands to the left side of the surgeon and the scrub nurse on their right. The monitor is positioned at the head of the bed in-line with surgeon and patient.

6.4.4 Operative Milestones Before trocar placement and insufflation the left costal margin and the planned gastrostomy site is marked (Milestone 6.1). These markings are helpful to avoid gastrostomy placement too close to costal arch when insuffla-

6.4.3 Trocar Placement The first (3 mm) trocar is placed at the umbilicus in an open technique preferably after injecting bupivacaine for early post-operative pain control. The capnoperitoneum is insufflated using a pressure of 10–12 mmHg and a flow of 1 l/min. Under vision a 2 or 3 mm trocar is placed left to the midline at the future gastrostomy site and used for an atraumatic grasper (Fig.  6.4). Alternatively 2 or 3  mm trocars can be placed in the left and right mid-abdomen for an atraumatic grasper and needle holder (Fig. 6.4).

Fig. 6.2  Positioning of patient, surgeons, endoscopist and monitor (school age children)

Milestone 6.1 Before trocar placement and insufflation the left costal  margin and the planned gastrostomy site is marked (Video  6.1  Nutritional access procedures_SR_rev_ML). (▸ https://doi.org/10.1007/000-2tz)

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse Endoscopist

Instrument table

30

S. Rohleder and T. Kawano

Fig. 6.3  Positioning of patient, surgeons, endoscopist and monitor (infants and small children)

Legend

Patient

Monitor Surgeon Assistant Scrub nurse Endoscopist

Instrument table

Legend

Trocar of laparoscopic grasper (gastrotomy planned site) Laparoscope trocar (Umbilicus) Working trocars (if necessary)

Fig. 6.4  Positioning of the trocars and gastrostomy site for laparoscopic assisted endoscopic gastrostomy

tion is applied. The gastrostomy site is to the left of the midline and usually half way between the umbilicus and the left costal margin. If the procedure is without gastroscopic assistance, the anesthetist should insert an orogastric tube in order to decompress the stomach at the beginning and insufflate 40–50 mL air during gastrostomy tube placement. If the liver obscures access to the stomach, it is suspended upwards towards the abdominal wall by encircling the falciform ligament using a percutaneous 2-0 polyglactin suture on a large needle. A gastrostomy placement along the anterior wall of the stomach close to the lesser curvature may be associated with a lower rate of

post-operative gastro-esophageal reflux [6]. However placement of the gastrostomy along the greater curvature, into the corpus allows the stomach to reach the abdominal wall tension-free and will less likely interfere in case fundoplication is required in the future. In any case, the gastrostomy needs to be placed far enough from the pylorus, so the balloon of the gastrostomy tube may not obstruct the gastric outlet. The selected part of stomach is then brought to the left anterior abdominal wall and three U-stitches are placed through the abdominal wall forming a triangle around the planed gastrostomy site using a large 37  mm half round needle on a Mayo-Hegar needle holder (Milestone 6.2). Using a 30° laparoscope, good vision can be achieved from different angles. If difficulties are encountered placing the stiches percutaneously, it is helpful to use a laparoscopic needle driver. Alternatively a suture device, like T-bar fixators or lasso suture retriever device can be used. The sutures are clamped and in the center of the gastrostomy site either a guidewire is entered over a percutaneous needle for the step dilator or a peelaway sheath on a trocar is placed under direct vision into the stomach (Milestone 6.3). While entering the lumen of the stomach traction is rather applied to the sutures than forcing the step dilator or the trocar into the stomach because care must be taken not to penetrate the posterior wall of the stomach. The use of an endoscope is of great help at this point. If the step dilator is used the gastrostomy is dilated in a Seldinger technique 4 Fr larger than the

6  Nutritional Access Procedures Milestone 6.2 U-stitches are placed through the abdominal wall; (a) by the use of a Mayo-Hegar needle driver, (b) by the use of laparoscopic needle driver, (c) by the use of a suture device of T-bar fixators, (d) by the use of a lasso suture retriever device

31

a

b

c

d

Milestone 6.3  While entering the lumen of the stomach, traction is rather applied to the sutures than forcing the step dilator or the trocar into the stomach

Milestone 6.4  The gastrostomy tube or button is placed into the stomach through the peel-away sheath and blocked. The traction sutures are tightened or secured with the button

planed gastrostomy tube. In order to place a button device primarily, a measuring device is recommended. The gastrostomy tube or button is placed into the stomach through the peel-away sheath and blocked (Milestone 6.4). The gastric wall should be smoothly approximated to the

abdominal wall now. If this is not the case, a shorter button is required. The traction sutures are tightened or secured over the button. When inserting  a gastric-jejunal device, placement over  a seldinger wire  simplifies the procedure (Milestone 6.5).

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S. Rohleder and T. Kawano

Milestone 6.5  Placement of the guied-wire prior to GJ-Tube placement into the duodenum and helps avoiding avoid intra gastric coiling by stabilizing the tube. (a) GJ-Tube entering the stomach in a Seldinger technique, (b) advancement of the GJ-Tube without intra-gastric coiling through the pylors

6.5

a

Postoperative Care

Postoperative pain is usually controlled with acetaminophen or NSAR. The gastric tube or the gastric port is drained to gravity for 24  h. Bolus feeding can be initiated then and gradually increased over the next 2–3  days. Postoperative complications include leakage at the gastrostomy site, skin irritations leading to formation of hypertrophic granulation tissue. This can be managed with topical skin protectants or silver nitrate. The traction sutures are removed after 2–3 days and a gastrostomy tube or button can be changed after 4–6 weeks. If dislocation of the tube occurs before, abdominal misplacement should be ruled out before feeding is continued.

6.6

Pearls/Tips & Tricks

1. Applying traction on the sutures while entering the lumen of the stomach and pulling the gastric wall over the needle/trocar on the peel-away sheath helps to prevent perforation of the posterior gastric wall. 2. By placing the gastrostomy at the anterior wall of the greater curvature instead along the lesser curvature of the stomach and never in the fundus, laparoscopic fundoplication will still be feasible if needed afterwards. 3. If a gastric-jejunal tube placement is planned, the guidewire should be advanced through the pylorus first and left in place while advancing the jejunal tube in a Seldinger technique to stabilize the shaft of the tube inside the stomach. If the placement of the guidewire is difficult or an acute sharp gastric angle is encountered, the guidewire can be directed by the use of an endoscopic forceps. 4. Placement of a gastrostomy in small infants or in a small volume stomach can be challenging and perforation of

b

the posterior wall can easily occur. This can be prevented by using simultaneous endoluminal (flexible) gastroscopy.

6.7

Pitfalls & Ways to Avoid

1. Final location of the gastrostomy can be easily misperceived if markings were omitted prior to insufflation the capnoperitoneum. A gastrostomy placement too close to the costal margin may cause dislocation of the gastrostomy tube or discomfort for the patient. 2. If the gastrostomy is placed too close to the pylorus or the length of the button is inappropriate, the balloon can obstruct the gastric outlet. 3. Before applying endoscopic gastric insufflation, all traction sutures should be placed under laparoscopic vision from different angles using the 30° laparoscope. After insufflating the stomach, laparoscopic view is noticeably reduced (Video 6.1).

References 1. Loser C, et  al. ESPEN guidelines on artificial enteral nutrition--percutaneous endoscopic gastrostomy (PEG). Clin Nutr. 2005;24(5):848–61. 2. El-Matary W.  Percutaneous endoscopic gastrostomy in children. Can J Gastroenterol. 2008;22(12):993–8. 3. Chung DH, Georgeson KE. Fundoplication and gastrostomy. Semin Pediatr Surg. 1998;7(4):213–9. 4. Lintula H, Antila P, Kokki H. Laparoscopic fundoplication in children with a preexisting gastrostomy. J Laparoendosc Adv Surg Tech A. 2003;13(6):381–5. 5. Acker SN, et  al. Is routine upper gastrointestinal contrast study necessary prior to laparoscopic gastrostomy tube placement in children? Eur J Pediatr Surg. 2016;26(1):29–33. 6. Plantin I, Arnbjornsson E, Larsson LT. No increase in gastroesophageal reflux after laparoscopic gastrostomy in children. Pediatr Surg Int. 2006;22(7):581–4.

7

Laparoscopic Pyloromyotomy Steffi Mayer, Illya Martynov, and Martin Lacher

7.1

Indications for Laparoscopic Approach to Pyloromyotomy

The indications for laparoscopic pyloromyotomy are the same as for the open approach. Several randomized controlled trials comparing laparoscopic and open techniques suggest an equivalent operating time and comparable length of hospital stay with reduced analgesics, improved cosmesis and significantly faster time to full feed for the laparoscopic approach [1, 2]. Moreover, the recurrence rate of reoperation after incomplete pyloromyotomy and rate of mucosal perforation have been proven to be equivalent [3].

7.2

Preoperative Workup and Considerations

The diagnosis of hypertrophic pyloric stenosis is typically based on the history of progressive projectile nonbilious vomiting and hypokalemic, hypochloremic alkalosis. The pyloric hypertrophy is confirmed by ultrasound. An adequate fluid resuscitation and electrolyte replacement is mandatory before surgery. In case of severe dehydration 10–20 mL/kg bolus of normal saline are administered followed by an infusion of 5% glucose in 0.45% saline at 1.5 times maintenance rate. Potassium chloride 10–20 mEq/L is added for associ-

ated hypokalemia when urine output is at least 1 mL/kg/hr. Electrolytes should be checked every 6 hours and the patient is ready for surgery when rehydrated, serum bicarbonate is less than 30 mEq/L, and serum chloride is over 100 mEq/L. A urinary catheter is not necessarily inserted, preoperative enemas are unnecessary, and we do not generally give perioperative antibiotics.

7.3

Anesthetic Considerations

Laparoscopic pyloromyotomy is typically performed under general anesthesia and endotracheal intubation. A naso- or orogastric tube is placed to decompress the stomach for the duration of the procedure. There is no need for epidural or spinal anesthesia. Hypothermia should be avoided.

7.4

Operative Technique

7.4.1 Equipment • • • • •

3 or 5 mm trocar for 30° scope 3 mm atraumatic grasper 3 mm atraumatic bowel grasper 3 mm blade monopolar cautery (grounding pad) 2–0 polyglycolic acid suture (closure of fascia)

7.4.2 Positioning Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_7. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App.

Supine frog leg-positioning at the end of the table with both arms tucked to the side (Fig.  7.1). The patient should be secured by tape to the table to allow a reverse Trendelenburg positioning during the procedure.

S. Mayer (*) · I. Martynov · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected] © Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_7

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Fig. 7.1  Positioning of patient, surgeons and monitor

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

Legend

Working trocar

Endoscope trocar

Milestone 7.1  Positioning of the pylorus. The hypertrophic pylorus is identified, the duodenum is grasped just behind it using an atraumatic grasper and the pylorus is directed anterior to the spine (Video 7.1 Lap_ Py_Springer_Version_FINAL). (▸ https://doi.org/10.1007/000-2v0)

7.4.4 Operative Milestones Fig. 7.2  Trocar placement

7.4.3 Trocar Placement The 5 mm trocar is placed in the umbilicus. The capnoperitoneum is insufflated using a pressure of 8 mmHg and a flow of 5 L/min and the 5 mm 30° scope is introduced. The instruments are placed without trocars through two stab incisions in the right upper quadrant for the left hand and para-­medially in the left epigastrium for the right hand (Fig. 7.2).

The liver is suspended upwards towards the abdominal wall using a non-absorbable 1–0 polypropylene suture on a large needle encircling the falciform ligament. The hypertrophic pylorus is identified by following the stomach and the postpyloric duodenum is gently grabbed with a 3  mm atraumatic grasper and directed anterior to the spine (Milestone 7.1). The serosa of the pylorus is incised longitudinally in the avascular area using a monopolar blade cautery in the right hand (Milestone 7.2). The monopolar blade and then one branch of the 3 mm atraumatic bowel grasper in the right hand is put into the mid-incision line and turned around by 90° to create access towards the muscular layer of the pylorus. Subsequently,

7  Laparoscopic Pyloromyotomy

the closed bowel grasper is inserted into the muscular layer and gently spread with a slow and steady motion to disrupt the muscle fibers stepwise from the gastric to the duodenal end of the pylorus (Milestone 7.3). Care is taken to generously spread into the antrum but rather minimal on the duodenal side of the muscle. The pyloromyotomy has been performed correctly, if the submucosa pops out between the two circular muscular halves, which can easily be moved against each other independently (‘shoe shine maneuver’; Milestone 7.4). To rule out mucosal perforation, 50ml air should be insufflated in the stomach while the left hand occludes the duodenum. In case of perforation air will be leaking at the site of the pyloromyotomy. The instruments are removed, and the abdomen is allowed to desufflate. Adhesive strips or skin glue is all that are required for skin closure.

7.5

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Milestone 7.2  Serosal incision. The pylorus is incised longitudinally in the avascular area with a monopolar blade cautery. Care is taken to extend this incision into the gastric antrum

Postoperative Care

The patient resumes oral feeds (breastmilk, formula) immediately after surgery. Parents have to be ensured that postoperative vomiting is typically in 50% of the patients and usually stops within days. Therefore, no food restriction or special diets are required [4]. Once the child is gaining weight on full enteral feeds (three feeds in a row without vomiting), they can be discharged home. Postoperative complications include insufficient pyloromyotomy and perforation.

7.6

Pearls/Tips & Tricks

1. If the umbilical stump is still present, the optic trocar can be placed through a transverse incision below the umbilicus. 2. Suspension of the liver upwards towards the abdominal wall using a non-absorbable 1–0 polypropylene suture on a large needle encircling the falciform ligament helps exposing the pylorus. 3. The duodenum is grasped immediately distal to the pylorus and the pylorus is lifted up and rotated towards the surgeon. Take care to gently grasp the entire circumference of the duodenum to avoid injury. If a trainee does his first pyloromyotomy the attending may hold the duodenum with his left hand himself/herself. The gastric and duodenal edges of the pylorus can be verified by palpation. Alternatively, a special long-curved clamp (Geiger clamp) can be used to stabilize the pylorus. 4. Push the pylorus tightly against the spine for stabilization to ensure that it will not slip away during the procedure. 5. The incision of the serosa with the monopolar blade should be straight forward in a single line to subsequently allow a complete separation of the seromuscular layer.

Milestone 7.3  Muscular spreading. The muscular layer of the pylorus is gently spread with a slow and steady motion from the gastric to the duodenal end using an atraumatic grasper.

Milestone 7.4  Shoe shine maneuver. The muscular cheeks of the pylorus are grabbed and moved against each other independently to confirm a successful pyloromyotomy.

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6. Care is taken to extend the pyloromyotomy towards the antrum to prevent insufficient spreading but to avoid extending it into the direction of the proximal duodenum where a mucosal perforation most likely occurs. 7. Spread the muscular layer carefully stepwise and give the muscular fibers enough time to separate.

7.7

Pitfalls & Ways to Avoid

1. Treat the duodenum gentle to prevent a duodenal tear, rupture, or perforation. 2. A mucosal injury can be dealt with in two ways [5]: Either a full-thickness closure of the myotomy and mucosal defect is performed. Subsequently, the pylorus is rotated 90° for a new pyloromyotomy. Alternatively, the musosal defect can be sutured primarily. Placing omentum over the repair is advised. Especially if you do not feel comfortable to tie intracorporal knots, you may convert to an open supraumbilical approach (Bianchi). 3. Preoperative placement of naso- or orogastric tube does not impact on length of hospital stay or postoperative vomiting but supports loss of gastric acid and is therefore only required in selected cases [6]. 4. Full enteral feeding is mandatory to dilate the pyloric canal. If this cannot be achieved and ultrasound confirms

persistent failure of relaxation of the pyloric canal, a laparoscopic redo pyloromyotomy has to be considered.

References 1. Oomen MW, Hoekstra LT, Bakx R, Ubbink DT, Heij HA. Open versus laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a systematic review and meta-analysis focusing on major complications. Surg Endosc. 2012;26(8):2104–10. 2. St. Peter SD, Holcomb GW III, Calkins CM, Murphy JP, Andrews WS, Sharp RJ, Snyder CL, Ostlie DJ.  Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg. 2006;244:363–70. 3. Hall NJ, Eaton S, Seims A, Leys CM, Densmore JC, Calkins CM, et  al. Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy. J Pediatr Surg. 2014;49:1083–6. 4. Adibe OO, Iqbal CW, Sharp SW, Juang D, Snyder CL, Holcomb GW, et  al. Protocol versus ad libitum feeds after laparoscopic pyloromyotomy: a prospective randomized trial. J Pediatr Surg. 2014;49:129–32–discussion132. 5. Waldron LS, St. Peter SD, Muensterer OJ.  Management and outcome of mucosal injury during pyloromyotomy: an analytical survey study. J Laparoendosc Adv Surg Tech A. 2015;25(12):1044–6. 6. Flageole HH, Pemberton J.  Post-operative impact of nasogastric tubes on length of stay in infants with pyloric stenosis (POINTS): a prospective randomized controlled pilot trial. J Pediatr Surg. 2015;50:1681–5.

8

Laparoscopic Duodenal Atresia Repair Oliver J. Muensterer and Andreas Lindner

8.1

Indications for Laparoscopic Approach to Congenital Duodenal Atresia

Laparoscopic duodenal atresia is indicated in infants born with duodenal obstruction not resulting from malrotation. The underlying etiologies of duodenal atresia or stenosis include complete atresia, duodenal web, and pancreas annulare. All these entities are treated with a proximal-to-distal bypass duodenoduodenostomy or duodenojejunostomy, leaving the papilla intact and unmanipulated. Laparoscopic duodenal atresia repair is a challenging procedure due to the small working space. Although absolute lower weight limits for laparoscopic duodenal atresia repair have not been established, very low birth weight infants (those under 1500  g) should probably only be operated by experts. Laparoscopic duodenal atresia repair has been shown to take longer but have a similar complication rate compared to the open approach [1, 2].

8.2

Preoperative Workup and Considerations

Typically, distension of the stomach and the proximal duodenum (the “double bubble sign”) is evident either on prenatal ultrasound or postnatal abdominal radiographs [3]. Most of these babies have bilious emesis or bilious drainage from a Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_8. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. O. J. Muensterer (*) · A. Lindner Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

decompressive nasogastric tube. If there is any doubt about possible malrotation and volvulus, an upper gastrointestinal contrast study and, if indicative for the diagnosis, prompt abdominal exploration is warranted. All other cases should undergo a careful preoperative workup and preparation for surgery. Trisomy 21 and associated cardiac anomalies should be considered and an echocardiogram performed [4]. A blood gas and electrolyte analysis should be obtained to rule out contraction alkalosis resulting from vomiting or gastric drainage. Any electrolyte imbalance should be corrected before surgery.

8.3

Anesthetic Considerations

Laparoscopic duodenal atresia is typically performed under general endotracheal anesthesia. Since about half of the patients are born prematurely and many have associated anomalies, these cases should be performed by an experienced pediatric anesthesiologist. Intraoperative bleeding is rare, but having blood available is advisable due to the complex nature of the procedure. At least 2 peripheral intravenous catheters should be available. Hypothermia should be avoided.

8.4

Operative Technique

8.4.1 Equipment • • • • • • •

2 or 3 mm instruments and trocars 3 mm 30° laparoscope 2 or 3 mm Maryland dissector 2 or 3 mm atraumatic grasper 2 or 3 mm needle holder 2 or 3 mm Metzenbaum scissors 2 or 3 mm hook monopolar cautery (grounding pad)

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_8

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• 2-0 braided polyglactin suture (to suspend the liver and duodenum transabdominally) • 5-0 braided polyglactin, 5-0 monofilament polydiaxone sutures (for the anastomosis)

8.4.2 Positioning Supine frogleg-positioning at the foot end of the bed with one arm extended sideways and one tucked to the side (Fig. 8.1). The patient should be secured by tape to the bed to allow for safe reverse Trendelenburg positioning and rotating the right side up during the procedure. Slight elevation of the right upper quadrant by placing a small towel or gauze pad bump under the right back is useful. The surgeon stands at the foot end of the bed, the monitor is at the head of the bed in-line with surgeon and patient. The assistant stands to the left side of the surgeon, the scrub nurse on their right. The umbilical cord should be cut after suture-ligating the umbilical stump close to its base. The abdomen is prepped and draped from the nipples to the symphysis.

8.4.3 Trocar Placement The first (3 mm) trocar is placed at the umbilicus, avoiding the umbilical vessels. The capnoperitoneum is insufflated using a pressure of 8 mmHg and a flow of 1 l/min. During the procedure, the insufflation pressure can be increased temporarily to provide sufficient working space. Under Vision, 2 or 3  mm trocars are placed in the right lower quadrant, the left upper quadrant, and possibly the left lower quadrant for an additional grasper if necessary (Fig. 8.2).

Fig. 8.1  Positioning of patient, surgeons and monitors

8.4.4 Operative Milestones After placement of the trocars, the liver is suspended upwards towards the abdominal wall using a percutaneous 2-0 polyglactin suture on a large needle. In some cases, suspending the gallbladder in a similar way provides additional exposure. The proximal, dilated duodenum is identified by following the stomach to the pylorus and beyond. It is mobilized from the surrounding structures, always respecting the porta hepatis with great care. The right colonic flexure is grasped and retracted inferiorly towards the patient’s left, using monopolar hook cautery to perform a Kocher-Maneuver and thereby expose the duodenal “C”, allowing the surgeon to identify the underlying pathology. The distal, poststenotic duodenum courses inferior and posterior to the proximal dilated portion behind the mobilized colon towards the left. It is mobilized to bring both parts of the duodenum together side-to-side (Milestone 8.1). It can be helpful to suspend both the proximal and/or the distal duodenum from the abdominal wall to help with alignment. The anastomosis is performed by incising the anterior surface of the proximal duodenum transversely and the distal portion longitudinally using the laparoscopic Metzenbaum scissors (Milestone 8.2). The posterior wall of the future anastomosis is then performed using interrupted 5-0 polyglactin sutures in a “diamond shaped” manner, meaning that the ends of one incision are sutured to the sides of the counterincision (Milestone 8.3). Knots are tied intraluminally for the posterior wall. Some surgeons place a transanastomotic tube at this time [5], although an uncontrolled study shown no benefit [6]. Subsequently, the anterior wall is sutured in a running fashion using a 5-0 polydiaxone suture. The anastomosis can be tested by insufflating the stomach with air and watching the air pass through the anastomosis into the distal duodenum

Legend

Patient

Monitor Surgeon Assistant Scrub nurse

Instrument table

8  Laparoscopic Duodenal Atresia Repair

39

Legend

Working trocar Endoscope trocar Accessory trocar

Fig. 8.2  Positioning of the trocars

Milestone 8.1  Alignment of the proximal, prestenotic and distal duodenum side-to-side for subsequent anastomosis (Video 8.1 DAVideo VAPES20180520HD_MPG4). (▸ https://doi.org/10.1007/000-2v1)

Milestone 8.3  Suturing of the postrior wall of the anastomosis using interrupted, 5-0 polyglactin sutures with the knots on the inside

Milestone 8.4  Final analstomosis. To test for patency, air is insufflated into the stomach and proximal duodenum, unobstructedly passing into the distal duodenum without an appreciable leak

without leakage (Milestone 8.4). This also helps excludes any windsock-type webs, which can be misleading.

8.5

Milestone 8.2  Enterotomy in the proximal (right) and distal (left) duodenum using the Metzenbaum scissors. In this case, an endoscope was placed in the proximal duodenum, its light visible in the circle on the right

Postoperative Care

A nasogastric tube is left in place and drained to gravity. Once the drainage decreased below 10 ml/kg/day, the nasogastric tube is removed and oral feeds are initiated with clear liquids. If clear liquids are tolerated, they can be advanced to breast milk or formula. Once the child is gaining weight on full enteral feeds, they can be discharged home. Postoperative complications include anastomotic leak and stenosis, although these are rare. Once on full feeds, these children usually do very well.

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Pearls/Tips & Tricks

1. In select cases, pure webs with or without a central aperture can be treated by making a longitudinal incision across the web and transverse full-thickness closure. 2. In cases with possible windsock-type anomaly, we perform an initial esophagogastroduodenoscopy and leave the endoscope in place during the laparoscopy for orientation. 3. A 5 mm endostapler can be used to perform a side-to-side duodenoduodenostomy, with subsequent manual suture closure of the resulting opening.

8.7

Pitfalls & Ways to Avoid

1. The distal portion of the duodenum can be difficult to identify. Additional mobilization of the colon medially (Kocher maneuver) can help identify the retroperitoneal fixation of the proximal small bowel. 2. If the distal duodenum is short, hypoplastic, or contains a windsock-type web that cannot be mobilized and resected, dissect the small bowel past the ligament of Treitz and perform an duodenojejunostomy in the same manner as described for the duodenoduodenostomy, only more distally.

3. In rare cases with associated malrotation, take down Ladd’s bands first and place the bowel in a nonrotational position (small bowel to the right, colon to the left), then proceed with duodenoduodenostomy as described. 4. Postoperatively, the nasogastric drainage can remain bilious although the child is ready for enteral feeds. Emphasis should be placed on drainage volume, not color.

References 1. Son TN, Kien HH. Laparoscopic versus open surgery in management of congenital duodenal obstruction in neonates: a single-center experience with 112 cases. J Pediatr Surg. 2017;52:1949–51. 2. Mentessidou A, Saxena AK.  Laparoscopic repair of duode nal atresia: systematic review and meta-analysis. World J Surg. 2017;41:2178–84. 3. Choudhry MS, Rahman N, Boyd P, Lakhoo K.  Duodenal atresia: associated anomalies, prenatal diagnosis and outcome. Pediatr Surg Int. 2009;25:727–30. 4. Stoll C, Dott B, Alembik Y, Roth MP.  Associated congenital anomalies among cases with down syndrome. Eur J Med Genet. 2015;58:674–80. 5. Arnbjörnsson E, Larsson M, Finkel Y, Karpe B. Transanastomotic feeding tube after an operation for duodenal atresia. Eur J Pediatr Surg. 2002;12:159–62. 6. Upadhyay V, Sakalkale R, Parashar K, Mitra SK, Buick RG, Gornall P, Corkery JJ.  Duodenal atresia: a comparison of three modes of treatment. Eur J Pediatr Surg. 1996;6:75–7.

Part II Small Intestine

9

Laparoscopic Approach to Malrotation Vikas Gupta and Samir Pandya

9.1

Indications for Laparoscopic Approach to Malrotation/Volvulus

Rotation abnormalities may be asymptomatic and can either be never diagnosed or incidentally found on imaging. More commonly, they are associated with obstruction caused by bands, midgut volvulus, or associated congenital anomalies such as atresias or webs. Severe cases of midgut volvulus can result in total intestinal ischemia and can be a significant cause of morbidity and mortality. As a result, timely diagnosis and intervention is of paramount importance in the management of rotational anomalies. In patients who are acutely ill and hemodynamically unstable, the authors do not recommend laparoscopy as a diagnostic or therapeutic modality. However, in patients who are diagnosed early or incidentally and are clinically stable, laparoscopy can be very effective.

9.2

Preoperative Workup and Considerations

In the pediatric population, bilious emesis is considered a surgical emergency. Mechanical obstruction and intestinal rotational abnormalities can present as green or yellow emesis, with or without abdominal pain or distention [1]. Urgent radiographic evaluation is warranted in cases of bilious (green) emesis. The gold standard of diagnosis is still an upper gastrointestinal (UGI) series. There has been some Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_9. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. V. Gupta · S. Pandya (*) Division of Pediatric Surgery, UT Southwestern Medical Center, Dallas, TX, USA e-mail: [email protected]

increasing interest in the use of transabdominal ultrasound as well as other modalities, such as computerized tomography (CT) scans or magnetic resonance imaging (MRI). However, to date, the UGI series is still the gold standard. A normal UGI should demonstrate the following: 1) The duodenum should cross midline and be found on the left of the spine 2) The duodenojejunal junction should be at the level of the antrum and 3) the duodenum should demonstrate a retroperitoneal course on lateral projection [1]. Absence of these suggests a rotational anomaly. The lack of progression of contrast or a corkscrew appearance of the duodenum down in the right hemi-abdomen is indicative of midgut volvulus. The surgical treatment for malrotation and midgut volvulus was first described by William Ladd in 1936, hence the eponym “Ladd’s procedure” [2]. Whereas the approach into the abdominal viscera are different for laparoscopy and open procedures, the key points of the procedure remain the same. For this publication, we will not review the open technique.

9.3

Anesthetic Considerations

In both the laparoscopic and open approach, general anesthesia is used. During laparoscopy, neonates may require lower insufflation pressures (8–10 mmHg) if at risk for reopening the left to right shunt. Adequate venous access should be obtained and perioperative antibiotics should be administered. Normothermia, normoglycemia and judicious amounts of intravenous fluids should be used.

9.4

Operative Technique

9.4.1 Equipment • 3 or 5 mm instruments and trocars • 3 or 5 mm 30° laparoscope • 3 or 5 mm Maryland dissector

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_9

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3 or 5 mm atraumatic grasper 3 or 5 mm Metzenbaum scissors 3 or 5 mm hook monopolar cautery (grounding pad) Endoloops or laparoscopic stapler (to divide the appendix and seal the base)

9.4.2 Positioning The patient is positioned supine frogleg-positioning at the foot end of the bed with one arm extended sideways and one tucked to the side. The surgeon stands at the foot end of the bed, the monitor is at the head of the bed in-line with surgeon and patient (Fig. 9.1). The assistant stands to the right side of the surgeon, the scrub nurse on the left. The abdomen is prepped and draped from the nipples to the symphysis.

9.4.3 Trocar Placement The size of the ports typically depends on the age and size of the patient; 3 mm ports are preferred for infants and 5 mm ports in older children. The optical port is placed in the umbilicus. An appropriately sized 30-degree camera is inserted to inspect the abdomen, and two additional trocars are placed (one on each side of the navel) along the mid clavicular line at the level of the umbilicus or slightly higher (Fig. 9.2). While the operation can be done with two working ports alone, the authors find the addition of an accessory port to provide significant advantage for bimanual retraction with simultaneous cautery/adhesiolysis. We position the accessory port on the laterally on the left hemiabdomen at the level of the umbilicus, however other locations can be also used to accommodate the handedness of the primary surgeon.

Fig. 9.1  Positioning of patient, surgeons and monitors

9.4.4 Operative Milestones After the placement of the trocars, the abdomen is explored to clearly visualize the patient’s intestinal and visceral anatomy (Milestone 9.1). If the patient is noted to have midgut volvulus with ischemia, conversion to laparotomy is advised [3]. Once the intestinal anatomy is clear, attention is turned to the adhesive bands between the cecum and the right upper quadrant abdominal wall (Milestone 9.2). These “Ladd’s bands” are divided using cautery, with great care not to cause inadvertent bowel or vascular injury (Milestone 9.3). The hook cautery can be used as both a dissecting tool and for adhesiolysis. It is imperative that all of the bands traversing the proximal duodenum are divided (Milestone 9.4), as residual adhesions will lead to recurrent obstructive symptoms. Exposure of these bands can be optimized by maximizing traction and counter traction with the laparoscopic instruments. As the duodenum is freed from adhesive bands, it can be progressively be retracted medially to expose additional Ladd bands that originate deeper in the retroperitoneum; these should be taken as well. Next, the duodenum and small bowel are mobilized into the right hemiabdomen to create a wide mesenteric base. This is facilitated by lysing of any filmy adhesions that are present along the small bowel mesentery. The colon is mobilized to the left hemiabdomen (Milestone 9.5). Subsequently, the colon is mobilized to the left hemiabdomen, and adhesive bands between the colon and small bowel are divided in an effort to further broaden the mesentery (Milestone 9.6). Ultimately, the cecum and appendix should be able to easily reach the left lower quadrant (Milestone 9.7). An extracorporeal appendectomy is performed by delivering the appendix through

9  Laparoscopic Approach to Malrotation

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Legend Working trocar Endoscope trocar

Milestone 9.3  Division of ladd’s bands

Fig. 9.2  Positioning of the trocars

Milestone 9.4 Release all retroperitoneal bands traversing the duodenum

Milestone 9.1  Confirmation of diagnosis with duodenojejunal junction right to midline. The ileocecal junction is also typically found in the right upper quadrant (Video 9.1 Laparoscopic Ladds Procedure). (▸ https://doi.org/10.1007/000-2v2)

Milestone 9.5 Division of adhesive bands between colon and duodenum

Milestone 9.2  Exposure of RUQ retroperitoneum and identification of Ladd’s bands

the umbilical or left-side port [4]. Finally, the cecum is laid into the left lower quadrant (Milestone 9.8). An important point to note is that, at the conclusion of the Ladd’s procedure, the intestinal anatomy will be identical to patients with non-rotation and not those with normal rotation. It is ideal to assess the width of the small bowel mesentery, which is approximated by the length between the

Milestone 9.6  Maximal broadening of the mesentery by lysing adhesions between the colon and small bowel

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Milestone 9.7  Placement of the cecum and appendex into the LLQ, followed by appendectomy

Milestone 9.8  Placement of cecum in the left lower quadrant

3. When determining the correct orientation of redundant duodeno-­jejunal junction (DJJ) and the cecum. While no small bowel, it can be helpful to begin at the pylorus or consensus or evidence based parameters exist, recent papers cecum and run the bowel distally or proximally respecdefine mesenteric length based on the diameter of the abdotively. The authors prefer starting at the cecum and pullmen. If the distance between the DJJ and the cecum is less ing the small bowel in the right lower quadrant to the than half of the diameter of the abdomen, it is considered to point where you can see the duodenum straight down. be “short.” Shortened small bowel mesentery puts the patient at risk for volvulus, and a Ladd procedure should be performed [5]. 9.7 Pitfalls & How to Avoid “Long” mesenteric length, longer than half of the abdominal diameter, is most consistent with nonrotation or near-­ 1. Recurrent malrotation or volvulus can be avoided by normal rotation patterns, and the risk of volvulus is low. In ensuring complete separation of abnormal adhesive bands these cases, a Ladd’s procedure is not indicated, but it is 2. Other possible complications include hemorrhage, important to divide any obstructive bands around the duodeabdominal pain, bowel injury, injury to other organs in num if present. Though practices are mixed in this circumthe abdomen, and cardiopulmonary or neurologic effects stance, appendectomy is generally performed to avoid future related to general anesthesia. Meticulous laparoscopic diagnostic confusion from a left-sided appendix [3]. technique that would be used under any other circumstance should be followed during even routine portions of the procedure (Video 9.1).

9.5

Postoperative Care

Postoperative care includes inpatient admission to the floor or ICU depending on the patient’s clinical status. For patients without bowel ischemia and/or resection, disposition is based on advancing diet as tolerated and transitioning to oral pain medication. Slower progression and return of normal bowel function may be necessary for patients who had more extensive operations.

9.6

Pearls/Tips & Tricks

1. Additional trocars can be placed in the right or left upper quadrant to provide additional retraction as needed. 2. To untwist a volvulus, the surgeon should rotate the bowel counterclockwise. This can be remembered by the adage “turning back the hands of time.”

References 1. Adams SD, Stanton MP. Malrotation and intestinal atresias. Early Hum Dev. 2014;90:921–5. 2. Ladd WE.  Surgical diseases of the alimentary tract in infants. N Engl J Med. 1936;215:705–8. 3. Langer JC.  Intestinal rotation abnormalities and midgut volvulus. Surg Clin North Am. 2017;97:147–59. 4. Luks FI.  Anomalies of intestinal rotation. In: Mattei P, editor. Fundamentals of pediatric surgery. New  York, NY: Springer New York; 2011. p. 373–80. 5. Mazziotti MV, Strasberg SM, Langer JC. Intestinal rotation abnormalities without volvulus: the role of laparoscopy. J Am Coll Surgeons. 1997;185:172–6.

Laparoscopic Treatment of Intussusception

10

Evgenij Werner and Oliver J. Muensterer

10.1 Indications for Laparoscopic Reduction of Ileocolic Intussusception Most ileocolic intussusceptions occur between 3 months and 3 years of age and are managed by imaging-guided hydrostatic or air enema reduction. If the first attempt of non-­operative reduction is unsuccessful, the procedure can be repeated once or twice in bi-hourly intervals [1]. Refractory cases are an indication for operative treatment, and a laparoscopic approach is preferable because it is less invasive, associated with quicker time to oral intake, and shorter hospital stay [2]. If needed, the laparoscopic incision at the umbilicus can be extended longitudinally to allow exteriorization and manual reduction, or resection and anastomosis if necrotic bowel is encountered. The main contraindication for a laparoscopic approach would be marked abdominal distension that precludes the safe placement of trocars.

10.2 Preoperative Workup and Considerations The history often includes episodes of crampy abdominal pain, followed by lucid intervals. Blood-tinged mucous from the anus, commonly referred to as “currant jelly stools”, is a late and unreliable finding. On physical exam, a sausage-like mass may be palpable in the right abdomen resulting from the intussuscepted bowel. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_10. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. E. Werner Department of Pediatric Surgery, Johannes Gutenberg University, Mainz, Germany O. J. Muensterer (*) Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

The most sensitive imaging modality for ileocolic intussusception is abdominal ultrasound [3], which demonstrates a target sign or a so-called “pseudo kidney sign”. In select cases, a contrast enema, or even a computed tomography scan may be indicated.

10.3 Anesthetic Considerations The patient should be resuscitated with intravenous fluids and a preoperative prophylactic dose of broad-spectrum antibiotics should be given. If the patient shows overt signs of mechanical bowel obstruction, rapid sequence intubation and measures to avoid aspiration are indicated.

10.4 Operative Technique 10.4.1 Equipment • 2 or 3 mm instruments and trocars • 3 mm 30° laparoscope • 2 or 3 mm atraumatic Babcock or bowel graspers

10.4.2 Positioning Young patients under 1 year of age are placed supine in frog leg-position at the foot end of the bed with one arm extended sideways and one tucked to the side (Fig. 10.1). Larger patients can be positioned supine with extended legs. The patient should be secured by tape to the bed to allow for safe airplaning to the left side to optimize the working space on the right. The surgeon stands on the patient’s left with the assistant to their right to hold the camera and sometimes, an additional instrument. The scrub nurse stands at the foot of the bed in young children, or to the surgeon’s left in older ones. The abdomen is prepped and draped from the nipples to the symphysis.

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_10

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Fig. 10.1  Positioning of patient, surgeons and monitors

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

10.4.3 Trocar Placement The first (3 mm) trocar is placed at the umbilicus. The capnoperitoneum is insufflated using a pressure of 8–12 mmHg, depending on size and age. During the procedure, the insufflation pressure can be increased temporarily to provide sufficient working space. Under Vision, 2 additional 3  mm trocars are placed in the left lower quadrant and the suprapubic position. To provide more overview of the abdomen during reduction, it may be helpful to move the camera to the left lower quadrant access site. Alternatively, an epigastric trocar can be placed to help stabilize reduced bowel (Fig.  10.2). Alternatively, the procedure can be performed in single-­ incision endosurgical technique through the navel only.

Legend

Working trocar Endoscope trocar Accessory trocar

Fig. 10.2  Positioning of the trocars

10.4.4 Operative Milestones After placement of the trocars and insufflation, the abdomen is inspected to confirm the diagnosis (Video 10.1). The intussusception is usually found in the cecum or ascending colon on the right. Occasionally, in so-called Waugh syndrome, intussusception is associated with malrotation, which makes the position of the intussuscepted mass more variable [4]. The intussuception is identified (Milestone 10.1), the bowel is gently grasped in a generous purchase, and gradual slow traction is applied. The small bowel is then held in place to allow edema to subside from the intussuscepted tissue, and the rim of the intussuscipiens (the colon) is rolled or pushed

over the intussusceptum (the small bowel) as seen in Milestone 10.2. This process is gently and patiently repeated until complete reduction is achieved. Sometime, a structural lead point is found (Milestone 10.3) which may require intervention. Meckel diverticula should be removed and lymph nodes suspicious for malignancy should be biopsied. The procedure is not complete until the ileum can be identified in its entirety to the ileocecal junction (Milestone 10.4). Traditionally, surgeons have performed an appendectomy after the reduction of ileocolic intussusception, but this custom is currently is not universally recommended any more. In our practice, we remove a grossly abnormal appendix, but

10  Laparoscopic Treatment of Intussusception

Milestone 10.1  Identification of the ileocolic intussusception (arrow) of the distal ileum into the cecum (Video 10.1 VAPES_Intussusception MPG). (▸ https://doi.org/10.1007/000-2v3)

Milestone 10.2  Rolling the cecum (intussuscipiens) over the ileum (intussusceptum) by stabilizing the ileum with one hand and gradually pushing the cecum over it distally

leave a macroscopically normal one in situ. A prophylactic ileopexy has not been shown to prevent recurrence, but is associated with longer operative times [2]. If the intussusception cannot be reduced by intracorporeal laparoscopic means, the umbilical incision can be extended in the craniocaudal direction to deliver the mass to the outside, allowing direct manipulation and retrograde reduction

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Milestone 10.3  Identification of a lead point, in this case a solitary enlarged lymph node. Some lead points may require resection (such as a Meckel diverticulum) or biopsy (such as unusual lymph nodes outside of the typical age range for the disease to rule out lymphoma)

Milestone 10.4 Verification of complete reduction by separately identifying the cecum, the appendix and the ileum, along with the completely reduced ileocolic junction (asterisk). Some surgeons would perform an appendectomy at this time

by the Hutchinson maneuver (squeezing the intussuscepted bowel proximally). If necrotic bowel is encountered at this time, it can easily be resected and an (extracorporeal) anastomosis performed.

50

10.5 Postoperative Care In uncomplicated cases, patients begin a normal diet as soon as they recover from anesthesia. A nasogastric tube is unnecessary. Patients should be monitored overnight for signs of recurrent intussusception, which has been described in about 10% of cases [5]. Appropriate analgesia should be given and most patients can be discharged home the following day.

10.6 Pearls/Tips & Tricks 1. Use gentle and gradual technique to allow for tissue edema to decrease during the procedure. 2. Always grasp the bowel with a good purchase to avoid crush injuries, serosal tears, or perforation. 3. Add an additional trocar to stabilize the already reduced bowel if it keeps reintussuscepting during the procedure. 4. Look for lead points that may require resection or biopsy, such as Meckel diverticula, polyps, or lymph nodes suggestive of lymphoma. 5. If unsuccessful, consider exteriorizing the bowel through a slightly enlarged umbilical incision for direct manipulation, reduction using the Hutchinson maneuver, or resection and anastomosis if the bowel is found to be necrotic.

10.7 Pitfalls & Ways to Avoid 1. Generally, larger instruments cause less tissue trauma because the grasping surface is larger. 2. If the ileocecal mass is not found in the right lower quadrant, the patient may have Waugh syndrome (associated

E. Werner and O. J. Muensterer

malrotation). In that case, the intussuscepted bowel may be located in the right or left upper quadrant. 3. Be prepared to convert to open procedure in complicated cases. 4. Ileopexy to avoid recurrent future intussusception has been found to be ineffective. 5. If the optic trocar in the umbilicus is too close, consider placing another trocar in the left lower quadrant for the endoscope and use the umbilical trocar for instrument access (Video 10.1).

References 1. Lautz TB, Thurm CW, Rothstein DH.  Delayed repeat enemas are safe and cost-effective in the management of pediatric intussusception. J Pediatr Surg. 2015;50:423–7. 2. Wei CH, Fu YW, Wang NL, Du YC, Sheu JC.  Laparoscopy versus open surgery for idiopathic intussusception in children. Surg Endosc. 2015;29:668–72. 3. Carroll AG, Kavanagh RG, Ni Leidhin C, Cullinan NM, Lavelle LP, Malone DE.  Comparative effectiveness of imaging modalities for the diagnosis and treatment of intussusception. A critically appraised topic. Acad Radiol. 2017;24:521–9. 4. Khan YA, Yadav SK, Elkholy A.  Waugh’s syndrome: report of two children with intussusception. Eur J Pediatr Surg Rep. 2017;5:e29–31. 5. Koh CC, Sheu JC, Wang NL, Lee HC, Chang PY, Yeh ML. Recurrent ileocolic intussusception after different surgical procedures in children. Pediatr Surg Int. 2006;22:725–8.

Laparoscopic Management in Crohn’s Disease: Ileocecal Resection

11

Laura Saura and Xavier Tarrado

11.1 Indications for Laparoscopic Approach in Crohn’s Disease

11.2 Preoperative Workup and Considerations

Crohn’s disease (CD) has a multifactorial etiology. The incidence around the world has increased rapidly, particularly in children 10–19 years of age. Up to 25% of new CD cases are diagnosed in childhood or adolescence [1, 2]. Despite optimized medical treatment with anti-tumor necrosis factor (TNF) agents that have modified the natural history of CD, still one-third of these patients will develop complicated disease and require surgery within five years of their initial diagnosis [3]. The aim of surgical treatment in pediatric CD is to overcome the consequences of the stricturing and penetrating inflammatory complications of the disease, while preserving as much bowel length as possible. Laparoscopic approach has gained acceptance in the management of pediatric CD and allow intestinal resection without need for a major laparotomy [4, 5]. Surgery must be an integral part in the overall management of CD and not a desperate last resort anymore. Children may enjoy years of symptomatic improvement and also get it through minimally invasive surgery [6].

Patients with Crohn’s disease who present partial or complete symptomatic obstruction, chronic abdominal pain or delay of growth despite escalated induction therapy, are those in whom surgery should be considered. Surgical chronic indications in CD include: ileocecal resections, small bowel stricture or fistula, colectomy for Crohn’s colitis and surgery for perianal disease. This chapter is focused on small bowel disease, and not in perianal and colonic involvement. The need for acute surgical intervention is relatively uncommon in pediatric CD. The workup for all patients should consist of:

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_11. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. L. Saura · X. Tarrado (*) Pediatric Surgery Department, Digestive, Thoracic and Minimally Invasive Surgery Unit, Hospital Sant Joan de Déu. University of Barcelona, Barcelona, Spain e-mail: [email protected]; [email protected]

• Evaluation of Pediatric Crohn’s Disease Activity Index (PCDAI), which includes clinical symptoms and laboratory study. • Magnetic resonance enterography (MRE) has become the imaging study of choice given its high accuracy and lack of ionizing radiation. Features as active inflammation, bowel wall thickening and pre-stenotic dilatation are clearly visualized. It is also useful to evaluate active segments of stricture or disease that are likely to respond to medical therapy, versus non-active strictures that probably would require surgery. Moreover, MRE can define the different patterns of the disease such as ileocecal CD, proximal small bowel or diffuse involvement. • Colonoscopy is required for histological confirmation especially in colonic disease and to evaluate the ileocecal valve. • Complete bowel preparation is not mandatory; as most of these patients are partially obstructed, it is usually not well tolerated. Liquid diet is recommended 48  hours before surgery. • If steroids were required to control acute disease, should be weaned as much as possible before surgery and

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_11

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p­ referably 4 weeks before surgery. The risk of perioperative anti-TNF agents are under debate. • Nutritional status should be optimized before surgery.

11.3 Anesthetic Considerations Laparoscopic surgical management for CD is performed under general anesthesia and endotracheal intubation. An orogastric tube is placed to decompress the stomach along the procedure; a urinary catheter is also placed. As intraoperative bleeding is possible having blood available is advisable. Prophylactic antibiotics are used during surgery and can be maintained afterwards depending on the operative findings. At least 2 peripheral intravenous catheters should be available. Central line is not always needed; and it depends mainly on the postoperative requirement of parenteral nutrition.

11.4 Operative Technique 11.4.1 Equipment • • • • • • • • • • • •

5 and 12 mm trocars 5 mm 30° laparoscope 5 mm dissector 5 mm atraumatic grasper 5 mm suction-irrigation device 5 mm scissors 5 mm needle-holder 5 mm hook monopolar cautery 5 mm electronic sealing-cutting device Linear stapler or endostapler 45–60 mm Plastic sleeve expandable wound protector 3/4–0 braided absorbable sutures

11.4.2 Positioning The patient is placed in supine position. The left arm is kept straight alongside the body. The surgeon and the camera assistant are on the patient’s left side. The scrub nurse is situated according to the surgeon preference. The monitor is placed on the right side at the level of iliac crest where it can be conveniently viewed by the operative team (Fig. 11.1).

11.4.3 Trocar Placement Three ports are usually sufficient, with a 12 mm port in the umbilicus (used for the telescope, the endoscopic stapler and for removal the specimen), and 5 mm ports in the left lower and upper quadrants. An accessory trocar can be placed in

Fig. 11.1  Trocar positioning and assistance incision in ileocecal laparocopic resection for CD

the right lower quadrant or in the right flank to help retraction and/or stapling device introduction) (Fig. 11.1).

11.4.4 Operative Milestones (Video 11.1) When laparoscopy is started revision of the whole bowel is performed to identify missed or new areas of the disease. The extension of ileocecal disease and the length of the bowel to be resected are determined. The proximal and distal ends are marked with stitches. Sometimes, when structures may be unrecognizable, following the tenia coli on the right colon toward the cecum can be helpful. Enteroenteric fistulae must be identified in order to avoid opening the lumen inadvertently during dissection, and to allow good orientation and delimitation. The identification of right ureter has to be done carefully as it lies underneath the ileocolic mesentery and could be accidentally injured. Ureteral stents are not routinely used, but can be considered if preoperative imaging suggests significant involvement of the inflammatory mass into the retroperitoneum. The ileum should be divided with an endoscopic stapler at the most distal point of relatively normal appearing bowel (Milestone 11.1). At this point, the mesentery is no longer thickened and the creeping fat subsides. Dissection of the mesentery is performed using an energy device and should be carried out as close to the bowel wall as possible, this will allow the surgeon to avoid potential undesirable injuries of underlying structures and allow to seal smaller mesenteric vessels. Moreover, as the mesentery is often very thick, accurate hemostasis must be done (Milestone 11.2).

11  Laparoscopic Management in Crohn’s Disease: Ileocecal Resection

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Right Toldt’s fascia is dissected upwards to achieve right colon mobilization and facilitate the anastomosis. A second endostapler is fired at the distal resection line, which is usually distal to the cecum. In the intracorporeal anastomosis a 5 cm long segment of both ends is fixed side-to-side whether joining the blind ends or overlapping them upside down. A 1 cm long enterotomy is performed in both bowel limbs at the same level. 45  mm endoscopic stapler is inserted through the 12  mm port to complete the anastomosis introducing each arm of the device through the enterotomies and fire it paying attention not to pinch the mesenteric supply (Milestone 11.3). The enterotomy for the stapler is closed using a running suture, interrupted stitches or an endostapler placed laterally. In order to perform extracorporeal anastomosis, the colon hepatic flexure should be taken down to allow easier exteriorization of the colonic limb through enlargement of the 5  mm ports in the right side or the umbilicus. A plastic expandable wound protector can facilitate this step. Side-to-­ side ileocolonic stapled anastomosis (Milestone 11.4) with a 45 mm cartridge is performed the same way that has been described intracorporeally.

Either way, once the anastomosis is completed, the mesenteric defect must be closed in order to avoid internal hernias with an absorbable running suture. The specimen is retrieved through the assistance incision or through the enlarged umbilical orifice. At the end of the surgery all the fascial and the skin incisions are closed and infiltrated with local anesthesia. Sometimes short segment, ileal or jejunal disease with pre-stenotic dilatation is identified in preoperative MRE or found incidentally during laparoscopy. In these cases, strictureplasty is a suitable accepted technique that will help to preserve bowel length. Standard Heineke-Mikulicz ­strictureplasty can be performed in most cases. An assistance incision is advisable as it is very important to establish the limits adequately (Milestone 11.5). When an enteroenteric fistula is identified during laparoscopy it should be carefully dissected leaving the penetrating area intact. It usually appears as healthy sigmoid or small bowel loop stuck into the inflamed ileum. Direct transection with an endoscopic stapler is performed after having checked that the residual lumen diameter of this loop is wide enough (Milestone 11.6).

Milestone 11.1  Division of the ileum just in the proximal limit of the affected CD segment (Video 11.1 Crohn_s Disease_XTarrado_LSaura_ FINALVERSIONFeb2020). (▸ https://doi.org/10.1007/000-2v4)

Milestone 11.3 5  cm long side-to-side stapled intracorporeal anastomosis

Milestone 11.2 Division of the mesentery/mesocolon close to the bowel wall all along the affected segment with a sealing device

Milestone 11.4 5  cm long side-to-side stapled extracorporeal anastomosis

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L. Saura and X. Tarrado

Milestone 11.5 Heinecke-­ Miculicz extracorporeal strictureplasty

Milestone 11.6  Enteroenteric fistula stapled transection

11.5 Postoperative Care A nasogastric tube is not routinely used in elective cases. Prophylactic antibiotics are maintained for 24 h. Total parenteral nutrition postoperatively is administrated in selected cases with poor nutritional status or severely ill. Most patients start having liquid diet on the first postoperative day. They can be discharged in 3–5 days and can return to normal activity in 1 or 2 weeks. All of them need medical maintenance treatment as prevention of recurrence after surgery. Postoperative clinical recurrence is measured with PCDAI and endoscopic recurrence is measured with Rutgeerts score in the follow-up (Fig. 11.2).

11.6 Pearls/Tips & Tricks 1. MRE is very useful preoperatively for the indication and surgical planning, and avoids guesswork during surgery.

Fig. 11.2  Scars of laparoscopic ileocecal resection with extracorporeal anastomosis

2. Laparoscopic approach is safe and effective for most isolated ileocolic disease. If there is a stiff phlegmon or multiple frozen loops of bowel surgery can be hazardous. In these cases conversion to open surgery or performing a temporary diverting ileostomy can be considered. 3. Marking with about 4 cm-long thread stitches both ends of the bowel can facilitate retraction (as thickening of the

11  Laparoscopic Management in Crohn’s Disease: Ileocecal Resection

bowel can make it difficult to grasp) and anastomosis creation by holding them together to align the limbs. 4. Strictureplasty has to be considered when short or/and multiple stenosis are found. Although it results into multiple intestinal sutures, it preserves bowel length which is a major goal in these patients. 5. Closing the mesenteric defect after extracorporeal anastomosis through a tiny assistance incision can be difficult. By twisting the plastic expandable wound protector the orifice can be sealed to complete the closure laparoscopically.

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fascia takes only a few minutes and avoids struggling long time while performing the anastomosis. 5. Missing significant strictures proximal to the ileocecal region can result in persistence of the obstructive symptoms postoperatively. Recent and accurate preoperative imaging study (especially MRE) and systematic intraoperative bowel inspection should be performed. 6. Twisting the limbs while performing anastomosis can cause intestinal obstruction. Careful inspection of both bowel ends and follow the V-shaped defect of the mesentery rule out missed distant bowel twist.

11.7 Pitfalls & Ways to Avoid 1. Administrate large volume of bowel preparation solution in all CD patients, despite the degree of obstruction; can result in acute obstruction symptoms and hinder the procedure because of the bowel distension. Low volume or no preparation must be considered. Liquid diet 48  h before surgery can be enough. 2. Fast and careless dissection of thickened mesentery containing large lymph nodes can result in copious bleeding. Division of the mesentery close to the bowel wall allows sealing smaller mesenteric vessels. Repeated applications of the sealing device are often needed to obtain effective hemostasis. 3. Dissecting towards the retroperitoneum to avoid the thickened mesentery can injure underlying structures. Mesentery division should be carried out as close to the bowel wall as possible. 4. Lack of right colon or hepatic flexure mobilization can difficult the side-to-side anastomosis, both laparoscopically or extracorporeally. Adequate dissection of Toldt’s

References 1. Amil-Dias J, Kolacek S, Turner D, et  al. Surgical management of Crohn disease in children: guidelines from the pediatric IBDP or to Group of ESPGHAN.  J Pediatr Gastroenterol Nutr. 2017;64(5):818–35. 2. Kim S. Surgery in pediatric Crohn’s disease: indications, timing and post-operative management. Pediatr Gastroenterol Hepatol Nutr. 2017;20(1):14–21. 3. Vernier-Massouille G, Balde M, Salleron J, et  al. Natural history of pediatric Crohn’s disease: a population-based cohort study. Gastroenterology. 2008;135(4):1106–13. 4. Dasari BV, McKay D, Gardiner K. Laparoscopic versus Open surgery for small bowel Crohn’s disease. Cochrane Database Syst Rev. 2011;1:CD006956. https://doi.org/10.1002/14651858.CD006956. pub2. 5. Stocchi L, Milsom JW, Fazio VW. Long-term out comes of laparoscopic versus open ileocolic resection for Crohn’s disease: follow­up of a prospective randomized trial. Surgery. 2008;144(4):622–8. 6. Surgical care of the pediatric Crohn’s disease patient. Semin Ped Surg. 2017;26:373–8.

Part III Colorectal

Laparoscopic Appendicectomy

12

Ibrahim A. Mostafa and Mohamed Sameh Shalaby

12.1 Indications for Laparoscopic Appendicectomy Laparoscopic appendicectomy is now widely accepted as a standard procedure for appendicitis. The most recent survey of the European Paediatric Surgeons’ Association showed 89% of the responders preferring laparoscopy for simple appendicitis and 81% for perforated ones [1].

12.2 Preoperative Workup and Considerations Antibiotics should be given at induction of anaesthesia, if they had not been started prior to that. Different antibiotic protocols exist for every centre but should include coverage of anaerobes and Gram-negative organisms. A urinary catheter is sometimes required in pelvic appendicitis.

12.3 Anaesthetic Considerations General anaesthesia is usually preferable. A nasogastric tube is seldom needed, only if prolonged ileus is anticipated.

12.4 Operative Technique 12.4.1 Equipment • The standard procedure requires 3 ports, one of them (usually the umbilical) should be 10–12  mm to allow retrieval of the appendix. The remainder are 5 mm ports. In complicated cases, if proper retraction cannot be achieved, a fourth port might be required. • A 5 mm scope is preferable. Zero- or 30-degrees scope is acceptable according to the surgeon’s preference. • At least 2 endo-loops; Polydioxanone (PDS®) or Polyglactin (Vicryl®). • One or two 5  mm atraumatic graspers, and a Kelly dissector • Monopolar hook diathermy, 5 mm. This mandates a diathermy pad to be placed. Other energy devices or staplers can also be used according to surgeon’s preference. • It is optional to have an endoscopic bag for appendix retrieval. This, however, may increase the cost and time of the procedure. • Suction & irrigation device, ideally with a specimen trap to get a sample of the peritoneal fluid.

12.4.2 Positioning

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_12. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. I. A. Mostafa · M. S. Shalaby (*) Department of Paediatric Surgery and Urology, Bristol Royal Children’s Hospital, Bristol, UK e-mail: [email protected]

Supine position. Trendelenburg’s position initially is helpful to move the bowel away from the pelvis with elevation of the right side. After appendix retrieval, reverse Trendelenburg’s position helps to collect the fluids in the pelvis for easier suction (Fig. 12.1).

12.4.3 Trocar Placement Figure 12.2 shows trocar sites. A supra-umbilical or infra-­ umbilical semi-lunar incision is done. Open Hasson’s technique is usually preferred in the paediatric population. The

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_12

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I. A. Mostafa and M. S. Shalaby

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

Milestone 12.1 Appendix in the right paracolic gutter (Video 12.1 Laparoscopic appendicectomy (Final)). (▸ https://doi.org/10.1007/000-2v5)

Fig. 12.2  Preferred ports sites

other two ports in the left iliac fossa and suprapubic area are inserted under vision.

12.4.4 Operative Milestones

Milestone 12.2  Subserosal portion of the appendix

It is essential to localize the appendix by following the taenia coli to the base of the appendix (Milestone 12.1), identifying if part of it is subserosal (Milestones 12.2 and 12.3). The second step is to mobilise and free the appendix from the bowel/peritoneal attachments followed by cauterisation and

division of the mesoappendix from the tip to the base of the appendix, ensuring good haemostasis (Milestone 12.4). When it comes to applying the endoloops to the base (Milestone 12.4), the surgeon should make sure a “faecolith” is not missed within the stump or the peritoneal cavity as it

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12.5 Postoperative Care

Milestone 12.3  The base of the caecum as marked by the taenia coli. Note the subserosal portion of the appendix

Antibiotics can be discontinued after laparoscopic appendicectomy for non-complicated appendicitis. In complicated cases, postoperative antibiotics are needed. Clear fluids can be allowed immediately after the operation unless prolonged ileus is expected (e.g. complicated appendicitis or where significantly dilated bowel loops were identified). Feeding is usually allowed shortly afterwards. Early mobilisation should always be encouraged. It reduces respiratory complications, ileus and venous thrombosis.

12.6 Pearls/Tips & Tricks

Milestone 12.4  Appendix after complete dissection

1. An appendix that is not easily visible at laparoscopy, is usually retro-caecal, retro-ileal or subhepatic. Be guided by the taenia coli to the base of the appendix. Missing a sub-serosal segment, which could extend up to the liver, may leave a long stump behind; creating a diagnostic dilemma in the future if it becomes inflamed. 2. The last endo-loop applied should be inserted through the port where the appendix is going to be retrieved. After tightening, don’t cut the endo-loop and use it to pull the appendix through. 3. There is a controversy whether to routinely carry out peritoneal irrigation after appendicectomy. It may spread a localised infection. If there is generalised peritonitis, irrigation is warranted.

12.7 Pitfalls & Ways to Avoid

Milestone 12.5  Amputated appendix

may predispose to post-appendicectomy collection. After cutting the appendix (Milestone 12.5), the last endoloop can be used to retrieve it via the umbilical 12  mm port. Some surgeons use an endoscopy bag routinely. The last step is the suction of any fluid found in the peritoneal spaces (pelvic, right iliac fossa, right paracolic gutter, Morrison’s pouch or subdiaphragmatic space). Irrigation is advised if there is purulent contamination.

1. Missing a sub-serosal portion of the appendix: The taenia coli marks the base of the appendix. The appendix should be dissected down to that level. The covering serosa should be dissected off the appendix properly. 2. Bladder injury during the suprapubic port insertion: If the bladder is significantly full and obscuring the view, a catheter should be used to empty it. 3. Missing a faecolith can predispose to post appendicectomy collection: A “bulky” portion of the appendix should be carefully examined for a faecolith. If the appendix couldn’t be retrieved in one piece, a careful look-around for a faecolith should be done.

Reference 1. Zani A, Hall NJ, Rahman A, Morini F, Pini Prato A, Friedmacher F, et  al. European Paediatric Surgeons’ Association survey on the management of pediatric appendicitis. Eur J Pediatr Surg. 2019;29(1):53–61. https://doi.org/10.1055/s-­0038-­1668139.

Single Incision Pediatric Endosurgical (SIPES) Appendectomy

13

Tatjana T. König and Oliver J. Muensterer

13.1 Indications for SIPES Appendectomy Appendectomy is the most frequent procedure to be performed via single incision endosurgery in children and has been shown to be safe and effective [1]. However, both the “conventional” three-port laparoscopic or open approach are widely used among pediatric surgeons [2]. SIPES appendectomy can be performed in cases of uncomplicated or complicated appendicitis, or interval appendectomy. Recently, the method was shown to be faster than conventional three port approach in uncomplicated appendicitis, with less perioperative pain [3]. There are no differences in the rates of wound infections, abscess or re-admission in cases of complicated appendicitis [3]. In obese patients, the SIPES appendectomy can be performed intra-abdominally [3].

13.2 Preoperative Workup and Considerations Patients typically present with pain and tenderness in the right lower abdominal quadrant with or without emesis. In early cases, pain may be projected to the midline, navel, or epigastrium. Later, signs of local or general peritonitis may be present. Especially in preschool children, clinical features might Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_13. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. T. T. König (*) Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany e-mail: [email protected] O. J. Muensterer Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

be atypical or misleading. Sonography of the right lower abdominal quadrant frequently reveals a target sign and free intraabdominal fluid. The white blood cell count is typically elevated. In cases of retrocecal appendices or obese patients, symptoms and ultrasound scan can be harder to interpret and an abdominal magnetic resonance imaging or low dose computed tomography scan might help to reduce the negative appendectomy rate and rule out differential diagnoses [2]. Broad-spectrum antibiotics should be administered preoperatively once the diagnosis is made. In case of an appendiceal mass, conservative treatment and possible later interval appendectomy should be considered. There is no evidence for increased rates of perforation or adverse outcomes, if appendectomy is performed within 24 hours of admission [4].

13.3 Anesthetic Considerations SIPES appendectomy is typically performed under general endotracheal anesthesia. Because of intestinal paralysis modified rapid sequence induction is warranted. Hypothermia should be avoided.

13.4 Operative Technique 13.4.1 Equipment • Flexible plastic-sheath wound retractor with gel lid or similar • 10 mm trocar, two 5 mm trocars • 45 cm long 5 mm 30° laparoscopes • 5 mm instruments • 5 mm Maryland dissector • 5 mm atraumatic grasper • 5 mm Metzenbaum scissors • 5 mm hook monopolar cautery (grounding pad) • 5 mm suction/irrigation device

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• 10 mm vessel sealing clip applicator, alternatively 10 mm or 5 mm stapler or endoscopic loop ties • Allis clamp • Groove director • 0-0, 2-0, 5-0 braided polyglactin suture • 5-0 absorbable monofilament suture • Transparent adhesive film (10 × 12 cm) and gauze ball for vacuum wound dressing

13.4.2 Positioning The patient is placed in supine position with the left arm tugged to the side. The right arm can be extended. The patient should be secured to the bed by a belt or tape for head-down position during laparoscopy. A grounding pad should be placed on either back or thigh. The abdomen is prepped and draped from the nipples to the symphysis. The surgeon performs the umbilical minilaparotomy from the patient’s right side, then moves to the left side for laparoscopy. The monitor is placed at the foot or right side of the patient (Fig. 13.1). Trendelenburg positioning and rotation to the patient’s left side might help to expose the appendix.

the patients’ size. The higher flows are useful since the trocar system often leaks gas during manipulation.

13.4.4 Operative Milestones To create access to the abdominal cavity, the umbilicus is infiltrated with local anesthesia and a vertical transumbilical incision is performed. The abdominal cavity is entered with blunt insertion of a closed clamp that is used to lift up and safely divide the fascia and peritoneum in the midline. The facial incision should be at least 2 cm long to comfortably fit the retractor (Fig.  13.3, Video 13.1). Wound retractors are available in different sizes. Larger patients may allow for longer incisions and bigger retractors. The trocars are positioned in the gel lid by the surgeon at an angle to create a maximum working range inside the abdominal cavity.

5 mm trocar

13.4.3 Trocar Placement

10 mm trocar

The plastic wound retractor is placed after vertical transumbilical midline minilaparotomy. The trocars are placed in the gel lid in triangular configuration at an angle before placing the lid on the retractor. The camera trocar is placed cranially and to the left (Fig. 13.2, Video 13.1). The position of the trocars can be changed by rotating the lid or re-introducing the trocars. The capnoperitoneum is insufflated using an age-­appropriate pressure of 10–14 mmHg and a flow of 2.5–10 l/min, depending on

Fig. 13.1  Positioning of patient, surgeons and monitors

wound retractor with lid

Fig. 13.2  Positioning of the trocars

Legend

Patient

Monitor Surgeon Assistant Scrub nurse Instrument table

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Fig. 13.3  Access to the abdominal cavity

Milestone 13.2  Milestone 2: dissection of peritoneal adhesions and mesoappendix

After appendectomy, the retractor is closed for further laparoscopy, and purulent fluid can be suctioned. After desufflation, the fascia is closed with a running absorbable suture. Especially in larger patients, a groove director might be helpful to bring up the fascia and protect underlying viscera. The skin is closed by intermittent subcuticular absorbable sutures. Milestone 13.1  identifying the appendix (Video 13.1 SIPES_Appen dectomy). (▸ https://doi.org/10.1007/000-2v6)

After establishment of the capnoperitoneum, the patient is placed in a Trendelenburg position. The appendix is identified and cleared of adhesions (Milestone  13.1 and 13.2, Video 13.1). In uncomplicated cases, the appendix can be brought through the single incision sight (“out” appendectomy). By lifting the lid, the abdomen is deflated and the assistant grabs the cecum or appendix with a swamp or an allice clamp. The mesoappendix is divided (Video 13.1). Quasi-open appendectomy can then be performed in a traditional way with a strong double base ligature (Milestone 13.3a, Video 13.1). According to surgeon’s choice, they can be reinforced with purse string- and/or figure-eight-sutures. Alternatively, endoscopic clips or stapler devices can be used on the outside. In cases of obese patients, fragile and severely inflamed appendices with a risk of rupture, or peritoneal adhesions, laparoscopic dissection and an appendectomy is performed intracorporeally using endoscopic loop ties, clips or a stapler (Milestone 13.3b, c). After closure of the appendiceal stump, appendectomy is performed removing the appendix through the wound retractor (Milestone 13.4). An endoscopic retrieval bag is optional, since the sleeve of the single-incision trocar usually protects the wound from direct contact with the inflamed appendix.

13.5 Postoperative Care Today, a fast track protocol after appendectomy is a standard of care in the pediatric population. Elements of a fast track surgery include sufficient pain management to allow mobilization with restrictive use of opioids, nutrition on the day of the operation, and avoidance of drains, tubes or catheters [5]. In uncomplicated appendicitis, even same-day discharge has been shown to be feasible and cost-effective [6]. In uncomplicated appendicitis, antibiotic treatment is discontinued postoperatively. In cases of complicated appendicitis, antimicrobial therapy can be stopped after five days, if leucocyte count has returned to normal [7]. If the leucocyte count is elevated, antibiotics should be administered for two more days before re-evaluation for discharge [7]. In cases of intraabdominal abscess, interventional drainage might be indicated.

13.6 Pearls/Tips & Tricks If you cannot exteriorize the appendix through the single incision site 1. Move the whole retractor in the direction of the right lower quadrant 2. Mobilize adhesions of the cecum to the abdominal wall

66 Milestone 13.3 (a–c) closure of the appendiceal stump (a) “out” appendectomy with strong double base ligature (b) “in” approach with clips (c) “in” approach with stapler

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a

b

c

Milestone 13.4 (a–c) dissection of the appendix

a

b

c

3. Use endoscopic loop ties, staplers or clips under direct view but inside the abdomen (“in” SIPES appendectomy). For intraabdominal removal, instruments and laparoscope might clash or seem crowded in the small incision. In order to create a good working space, move the instruments towards and away from the camera (in the z-axis) instead of to the sides (x- and y-axis). In cases of negative appendicitis, the bowel should be run through the singe incision site to rule out other reasons for abdominal pain such as a Meckel’s diverticulum. Running

the bowel through the incision on the outside is often quicker than manipulating it intracorporeally with laparoscopic instruments. To avoid dead space in the wound and promote a good cosmetic outcome, a vacuum dressing can be applied to the umbilicus (Fig. 13.4). After closing the skin, a dry gauze ball is placed in the umbilicus and covered with adhesive film (e.g. 10 × 12 cm). The vacuum is created by a 5 ml empty syringe. The needle should be applied through the skin into the cotton ball. This method has been shown to reduce the infection rate in cases of SIPES appendectomy [8].

13  Single Incision Pediatric Endosurgical (SIPES) Appendectomy

Fig. 13.4  Vacuum wound dressing

13.7 Pitfalls & Ways to Avoid In order to minimize the risk of perforation, a severely inflamed appendix should be grabbed by the mesoappendix and not the appendix itself whenever possible.

References 1. Saldaña LJ, Targarona EM.  Single-incision pediatric endosurgery: a systematic review. J Laparoendosc Adv Surg Tech A. 2013;23(5):467–80. 2. Bolmers MD, van Rossem CC, Gorter RR, Bemelman WA, van Geloven AAW, Heij HA; Snapshot Appendicitis Collaborative

67 Study group. Imaging in pediatric appendicitis is key to a low normal appendix percentage: a national audit on the outcome of appendectomy for appendicitis in children. Pediatr Surg Int 2018;34(5):543–551. 3. Wieck MM, Hamilton NA, Krishnaswami S. A cost and outcome analysis of pediatric single-incision appendectomy. J Surg Res. 2016;203(2):253–7. 4. Cameron DB, Williams R, Geng Y, Gosain A, Arnold MA, Guner YS, Blakely ML, Downard CD, Goldin AB, Grabowski J, Lal DR, Dasgupta R, Baird R, Gates RL, Shelton J, Jancelewicz T, Rangel SJ, Austin MT. Time to appendectomy for acute appendicitis: A systematic review. J Pediatr Surg. 2018;53(3):396–405. 5. Reismann M, Arar M, Hofmann A, Schukfeh N, Ure B. Feasibility of fast-track elements in pediatric surgery. Eur J Pediatr Surg. 2012;22(1):40–4. 6. Litz CN, Stone L, Alessi R, Walford NE, Danielson PD, Chandler NM.  Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis. J Pediatr Surg. 2018;53(4):625–8. 7. Desai AA, Alemayehu H, Holcomb GW III, St Peter SD. Safety of a new protocol decreasing antibiotic utilization after laparoscopic appendectomy for perforated appendicitis in children: A prospective observational study. J Pediatr Surg. 2015;50(6):912–4. 8. Muensterer OJ, Keijzer R. A Simple Vacuum Dressing Reduces the Wound Infection Rate of Single-Incision Pediatric Endosurgical Appendectomy. JSLS. 2011;15:147–50.

Single-Incision Pediatric Endosurgical (SIPES) Appendectomy using a Glove Port

14

Illya Martynov and Martin Lacher

14.1 Indications for Laparoscopic Approach to Acute Appendicitis The surgical approach for acute appendicitis has remained the mainstay of treatment for over 120 years [1]. Since the 1980s, laparoscopic appendectomy has gained popularity and has been shown to have several advantages over open appendectomy including shorter hospital stay, lower incidence of local site infections and better cosmetic outcomes [2, 3]. Laparoscopic appendectomy using a single transumbilical incision instead of traditional 3-port approach provides additional advantages such as better cosmetic outcome without leaving any appreciable scar [4–7]. Transumbilical port systems using a surgical glove may replace commercial ports as a cost effective method with improved ergonomics [7–10].

14.2 Preoperative Workup and Considerations The diagnosis of acute appendicitis continues to be a medical challenge. In addition to clinical and laboratory findings, ultrasound should be the imaging of choice in children. Preoperatively, a urinary catheter, nasogastric tube or preoperative enemas are not necessary. We give broad-spectrum

parenteral antibiotic prophylaxis (ampicillin with sulbactam or similar) prior to surgery.

14.3 Anesthetic Considerations Laparoscopic appendectomy is typically performed under general anesthesia and endotracheal intubation. Sufficient muscle relaxation is essential for the establishment of optimal work place, especially when the bowel loops are dilated. A single large-bore intravenous line is placed. Hypovolemia, electrolyte, and acid-base disturbances are to be corrected.

14.4 Operative Technique 14.4.1 Equipment (Figure 14.1) • Double ring wound retractor • Size 6.5 latex sterile powder-free surgical glove • 5  mm 45-cm laparoscope with a 90° angulated light adapter • 5 mm atraumatic grasper • Monopolar hook • Polyglactin suture 2-0 on a UR-6 needle

14.4.2 Positioning Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_14. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App.

Supine positioning with arms tucked to side and legs spread slightly apart with routine padding. The surgeon and the assistant stand on the left, the scrub nurse on the right side.

I. Martynov (*) ∙ M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]

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The monitor is placed on the right side of the patient (Fig. 14.2).

14.4.3 Trocar Placement A 5 mm 45-cm laparoscope is introduced through the before sliced thumb of the glove port into the abdominal cavity and a capnoperitoneum of 8–12  mmHg and flow of 4–6  L/min is

Fig. 14.1  Equipment for single-incision laparoscopic pediatric endosurgery with glove port

established. The fixation of a 5 mm trocar to the wound retractor prevents its dislocation. Furthermore, it allows the safe introduction of sharp instruments through the port. A 5 mm atraumatic grasper and monopolar hook are introduced in abdominal cavity through a 2 mm incision in the fingertips.

14.4.4 Operative Milestones A 2-cm vertical incision is made in the fascia underlying the umbilicus to enter the peritoneal cavity. A double-ring wound retractor is placed directly through the fascia (Fig.  14.3, Milestone 14.1), and a size 6.5 latex sterile powder-free surgical glove is connected to it (Milestone 14.2). The thumb of the glove is cut off and a 5 mm trocar is introduced into the abdomen for CO2 insufflation and tied to the wound retractor to prevent dislocation (Milestone 14.3). A 5 mm 45 cm laparoscope is connected to the light cord using a 90° angulated light adapter and introduced through a 2 mm incision in one of the fingertips (Milestone 14.4). Diligent and systematical exploration of the abdomen including inspection of distal small bowel to evaluate for a possible Meckel’s diverticulum is performed to confirm the diagnosis. In females, ovaries, fallopian tubes and uterus should be explored. With standard reusable 5-mm straight laparoscopic instruments (two atraumatic graspers), the appendix is identified following the taenia coli to their confluence at the base of the cecum. The appendix (or in case of severe inflammation the mesoappendix) is grabbed 1.5 cm proximal of its apex and the mesoappendix is divided creating the window in the mesentery using monopolar hook introduced through the 5 mm

Fig. 14.2  Positioning of patient, surgeons and monitors

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

14  Single-Incision Pediatric Endosurgical (SIPES) Appendectomy using a Glove Port

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Milestone 14.2  Connection of surgical glove to wound retractor Fig. 14.3  Hitch stich to facilitate removal of the wound tetractor

Milestone 14.1  Placement of the wound retractor (Video 14.1 Single-Incision-Laparoscopic-­A ppendectomy-Springer_Book). (▸ https://doi.org/10.1007/000-2v7)

Milestone 14.3  The fixation of 5 mm trocar between trocar valve and the wound retractor

trocar (Milestone 14.5). Afterwards, the appendix is grabbed, exteriorized and amputated over a polyglactin suture ligation extracorporeally (Milestone 14.6). Optionally, a cauterization of the appendix stump can be performed. The fascial incision is approximated with a running 2-0 polyglactin suture. Finally, the skin incision is closed using interrupted subcuticular 4-0 poliglecaprone sutures.

administrated as needed. In patients with complex appendicitis and perforation, the antibiotics are continued postoperativey.

14.5

Postoperative Care

In patients with simple, non-perforated appendicitis, there is no need for additional postoperative antibiotics. Enteral feeding is introduced a few hours after surgery. Analgesia is

14.6 Pearls/Tips & Tricks 1. The fixation of a 5 mm trocar to the wound retractor prevents dislocation and allows the introduction of sharp instruments through the port as the tip of the port cannot violate the glove. 2. All other instruments (second grasper and the camera) can be introduced through the 2 mm incisions in the fingertips, therefore time-consuming connection of special cannulas or trocars is not necessary.

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Milestone 14.4  Introduction of a 5 mm 45-cm scope through an incision in the fingertip

I. Martynov and M. Lacher

Milestone 14.6  Amputation of the exteriorized appendix

at risk for injury during the dissection of the appendix. The surgeon should be aware of the surrounding anatomy. 3. Single port laparoscopic appendectomy is more difficult to learn, master and perform than multiport appendectomy. Stable video camera control, mastery to overcome limited degree of freedom of laparoscopic instruments, spatial awareness of two-dimensional imaging and good ergonomics are mandatory to complete the operation smoothly and efficiently. 4. The self-made glove port is an off-label product. It should be used at the surgeon’s discretion.

References Milestone 14.5  Division of the mesoappendix

3. The hitch stich to the wound retractor allows easy removal at the end of the procedure. 4. The long, angled laparoscope in combination with the 90° angled light connector avoids clashing of instruments and the instruments and the telescope/camera head.

14.7 Pitfalls & Ways to Avoid 1. The gentle dissection of mesoappendix is crucial and tearing of it can result in bleeding from the appendiceal artery or its branches. Careful hemostasis should always be maintained. 2. Especially in case of retrocecal position of appendix or in the presence of extensive inflammation, the right ureter is

1. McBurney CIV. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg. 1894;20(1):38–43. 2. Aziz O, Athanasiou T, Tekkis PP, et  al. Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg. 2006;243(1):17–27. 3. Sauerland S, Jaschinski T, Neugebauer EA.  Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010;(10):Cd001546. 4. Perez EA, Piper H, Burkhalter LS, Fischer AC. Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis. Surg Endosc. 2013;27(4):1367–71. 5. St Peter SD, Adibe OO, Juang D, et al. Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial. Ann Surg. 2011;254(4):586–90. 6. Lacher M, Muensterer OJ, Yannam GR, et al. Feasibility of single-­ incision pediatric endosurgery for treatment of appendicitis in 415 children. J Laparoendosc Adv Surg Tech A. 2012;22(6):604–8. 7. Martynov I, Lacher M.  Homemade glove port for single-incision pediatric endosurgery (SIPES) appendectomy-how we do it. Eur J Pediatr Surg Rep. 2018;6(1):e56–8.

14  Single-Incision Pediatric Endosurgical (SIPES) Appendectomy using a Glove Port 8. Lee SM, Hwang GS, Lee DS. Single-incision laparoscopic appendectomy using homemade glove port at low cost. J Minimal Access Surg. 2016;12(2):124–8. 9. Mahdi BD, Rahma C, Mohamed J, Riadh M.  Single-port laparoscopic surgery in children: a new alternative in developing countries. Afr J Paediatr Surg. 2015;12(2):122–5.

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10. Di Saverio S, Mandrioli M, Birindelli A, et al. Single-incision laparoscopic appendectomy with a low-cost technique and surgical-­ glove port: “how to do it” with comparison of the outcomes and costs in a consecutive single-operator series of 45 cases. J Am Coll Surg. 2016;222(3):e15–30.

Laparoscopic Management in Ulcerative Colitis: Staged Proctocolectomy with Ileal Pouch-Anal Anastomosis

15

Pedro Palazón and Xavier Tarrado

15.1 Indications for Laparoscopic Approach to Ulcerative Colitis

15.2 Preoperative Workup and Considerations

Approximately 20–45% of all patients with ulcerative colitis Surgical options will be dictated by type of surgery (emer(UC) will need surgery. In children, pancolitis is the most gent or elective surgery) nutritional and clinical status, common presentation at diagnosis, and at least 25% will patient preferences and the dose and duration of steroid require an urgent operation [1, 2]. therapy. Surgical treatment is curative. Total proctocolectomy The safest surgical option in the emergent situation is an with ileal pouch-anal anastomosis has become the gold stan- initial subtotal colectomy leaving a rectal stump and a prodard [3, 4]. tective ileostomy. When the child recovers and normalizes Indications for elective surgery: nutritional status, proctectomy with ileal pouch-anal anasto–– Refractory disease: persistent symptoms despite opti- mosis (IPAA) is performed, with or without a new protective mized medical treatment. ileostomy. Ileostomy closure is usually performed 2 or –– Disease-related sequelae or unacceptable side effects 3 months afterwards. from an aggressive medical therapy: derangements in In an elective scenario, principles and stages for laparogrowth, nutritional status or quality of life. scopic repair are usually the same as for the emergent situa–– Colonic dysplasia or malignancy. tion. However, in a patient with good clinical and nutritional Indications for emergent surgery: status, a two-stage surgery could be proposed in experienced –– Fulminant disease: worsening symptoms or non-­ hands: total proctocolectomy and IPAA with protective ilecontrolled disease (PUCAI score ≥ 65) despite escalated ostomy; ileostomy closure in 2–3 months [1–5]. Crohn’s dismedical therapy. ease should be ruled out before restorative IPAA. –– Toxic megacolon or sepsis for longer than 24–48  h in Preoperative workup should include: spite of intensive medical measures. –– Evaluation of the disease progress, effectiveness of medi–– Colonic perforation. cal therapy and quality of life through Pediatric Ulcerative –– Uncontrolled colorectal bleeding [4, 5] Colitis Activity Index (PUCAI). Minimal invasive surgery is feasible and safe. It is recom- –– Nutritional strategies to improve patient condition. mended as there are similar functional long-term outcomes However, delay in surgical intervention to optimize nutrito open surgery, both for emergent and elective cases. There tional status is not recommended. are no absolute contraindications to laparoscopy [6]. –– Laboratory markers analysis. Anemia, hypoalbuminemia and electrolyte abnormalities should be corrected preopSupplementary Information The online version contains supplemeneratively. Transfusion when necessary. tary material available at https://doi.org/10.1007/978-3-030-58043-8_15. The videos can be accessed individually by clicking the DOI link in the –– Endoscopic mucosal evaluation and tissue biopsies. Evaluate response to treatment and rule out accompanying figure caption or by scanning this link with the SN More Media App. Cytomegalovirus (CMV) and Crohn’s disease. – – Psychological status evaluation; provision of appropriate P. Palazón · X. Tarrado (*) support (ileostomy). Pediatric Surgery Department, Digestive, Thoracic and Minimally Invasive Surgery Unit, Hospital Sant Joan de Déu. University of Prednisolone >20 mg/day is associated with an increased Barcelona, Barcelona, Spain risk of surgical complications. However, in an acute setting, e-mail: [email protected]; xtarrado@ sjdhospitalbarcelona.org

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corticosteroid therapy should be maintained to avoid a flare­up of colitis and surgery should not be delayed. There are insufficient data regarding anti-TNF therapy but colectomy should be postponed, if possible, 4–6  weeks after the last Infliximab infusion [4]. Oral intake is restricted to liquids for 48 h preoperatively. Gentle administration of hyperosmolar polyethylene glycol solutions could be used for bowel preparation in elective cases. Enemas should be avoided because they may stimulate an acute flare-up of colitis. Anticoagulation to prevent venous thromboembolic event is recommended when risk factors are present. Management of toxic megacolon includes high-dose steroids and fluid therapy, intravenous broad-spectrum antibiotics, insertion of a nasogastric and rectal decompression tube. Clinical condition should be closely monitored with serial physical examination, blood test and abdominal X-ray to warrant an early surgery when indicated.

15.3 Anesthetic Considerations Laparoscopic management of UC is performed under general anesthesia and tracheal intubation. A decompressive nasogastric tube and vesical catheter are placed and maintained throughout the procedure. Broad-spectrum antibiotic prophylaxis is used perioperatively. Having blood available is mandatory due to the complex nature of the procedure and the risk of hemorrhage, especially in emergent surgery. At least two peripheral intravenous catheters are necessary. Central line insertion depends on patient condition and nutritional status.

15.4 Operative Technique 15.4.1 Equipment • • • • • • • • • • • • • •

5 and 12 mm trocars 5 mm 30° telescope 5 mm Maryland dissector 5 mm atraumatic grasper 5 mm needle holder 5 mm Metzenbaum scissors 5 mm suction irrigation device 5 mm hook monopolar cautery 5 mm electronic sealing and cutting device Endolinear stapler 45 mm Linear stapler 45 mm—60 mm Circular mechanical stapling device Plastic expandable wound protector 3/4–0 braided reabsorbable sutures

15.4.2 Positioning Patient is placed in supine position on the operating table. Legs are positioned on basic stirrups and kept apart. All pressure points should be well padded to avoid pressure-related injuries. Arms are kept straight alongside the body. Patient should be secured to the bed to let swing the position of the table during the procedure. Protective ileostomy site is preoperatively marked. Patients are entirely prepped and draped, from legs to nipples, to allow conversion and sterile mobilization. • Subtotal colectomy. Surgeon and camera assistant stand facing the colon segment being dissected. Surgical team stand on patient’s right side while left colon is mobilized (Fig. 15.1). When transverse colon is dissected, the surgeon moves between the legs (Fig.  15.2). During right colon and ileocecal mobilization, surgeon and the camera assistant move to the left side of the patient (Fig. 15.3). Colectomy could be performed right-to-left or left-to-­ right, according to the surgeon preferences. • Proctectomy and IPAA. Surgeon and camera assistant are on patient’s right side. Surgical assistant stands between patient’s legs for transanal anastomosis (Fig. 15.4).

15.4.3 Trocar Placement The capnoperitoneum is insufflated using a pressure of 12–14 mmHg and a flow of 3–4 l/min. • Subtotal colectomy. The first (5 mm) trocar is placed at the umbilicus and is used for the telescope. Three working 5 mm ports are placed at the right upper, left upper and left lower quadrants of the abdomen. A 12 mm trocar is placed at ileostomy site in the right lower quadrant for the endoscopic stapler and to retrieve the specimen (Fig. 15.5). A diamond-­shape placement of the trocars is a common alternative (hypogastrium, epigastrium and both flanks). • Proctectomy and IPAA. The first (12 mm) trocar is placed at the umbilicus and is used for the telescope and endoscopic stapler. Two working 5 mm ports are placed at the same sites as for colectomy: left upper and left lower quadrants of the abdomen. A new 5 mm trocar is placed at the right lower quadrant, next to the ileostomy. Once the ileal pouch is created and placed into the abdominal cavity, a 12 mm trocar is left at the ileostomy orifice to help exposing the anal anastomosis (Fig. 15.6).

15  Laparoscopic Management in Ulcerative Colitis: Staged Proctocolectomy with Ileal Pouch-Anal Anastomosis Fig. 15.1  Positioning of patient, surgeons and monitors in subtotal colectomy. Descending colon dissection

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Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

Fig. 15.2  Positioning of patient, surgeons and monitors in subtotal colectomy. Transverse colon dissection

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

15.4.3.1 Operative Milestones (Video 15.1) • Subtotal colectomy: After placement of the trocars, colon mobilization is started on the left side, just at the rectosigmoid junction. Toldt’s fascia is easily divided with monopolar cautery. Rectosigmoid mesocolon is opened with a sealing-cutting device. The mesentery is sometimes very thick so a careful dissection with an accurate hemostasis must be done. The dissection is continued proximally up to the splenic flexure. It should be close to the bowel wall in order to seal small vessels and to

avoid injuring underlying structures. It is helpful at this moment to divide the rectosigmoid junction with an EndoGIA (Milestone 15.1). Once the splenic flexure is reached, greater omentum is preserved and completely released from the transverse colon, allowing a clearer vision for the transverse mesocolon division. This maneuver is easily performed if the surgeon stands between the legs and the operation table is positioned in reverse Trendelenburg. Mobilization of the hepatic flexure of the colon must be careful, ensuring a clear identification of the duodenum to avoid unnoticed inju-

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Fig. 15.3  Positioning of patient, surgeons and monitors in subtotal colectomy. Ascending colon dissection

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse Instrument table

Fig. 15.4  Positioning of patient, surgeons and monitors in proctectomy and IPAA

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

ries. A reverse Trendelenburg and tilt of the operating table to the left may help the dissection. Dissection from the ileocecal region upwards may help to release the hepatic flexure and identify the duodenum if difficulties are found when doing it downwards. Right mesocolon is divided as close to the colon as possible to save the marginal artery branches and the right colic artery. Once the colon is totally mobilized, the right lower quadrant trocar is widened to allow its exteriorization with the wound protector. Terminal ileum is then divided with an open GIA and an ileostomy is performed (Milestone 15.2).

• Proctectomy and IPAA: After placement of the trocars, the rectal stump should be identified and isolated from the surrounding tissues. Care should be taken to identify both ureters before starting the dissection. Once the rectal stump is clearly delimited, a careful mobilization should be continued downwards, as close as possible to the rectal wall to avoid injuries to the ureters, uterus, vagina, obturator vessels, vas deferens and sacral plexus (Milestone 15.3). The limit of dissection is the levator muscle, 2–3  cm above the dentate line. It is useful to perform a simultaneous rectal digital exam. The rectal stump is divided at

15  Laparoscopic Management in Ulcerative Colitis: Staged Proctocolectomy with Ileal Pouch-Anal Anastomosis

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Legend

5mm working trocar 5mm endoscope trocar 12mm accessory trocar

Fig. 15.5  Positioning of the trocars in subtotal colectomy

Milestone 15.2  Terminal ileostomy after colectomy

Legend 5mm working trocar 12mm endoscope trocar Ileostomy

Fig. 15.6  Positioning of the trocars in proctectomy and IPAA

Milestone 15.3  Rectal dissection down to the pelvis close to its wall

Milestone 15.1  Rectosigmoid division. (▸ https://doi.org/10.1007/000-2v8)

the distal margin of dissection with an EndoGIA deflectable linear stapler (Milestone 15.4). The rectal specimen is retrieved afterwards through the ileostomy site defect. IPAA is performed with a double-stapled technique (DS-IPAA). Ileostomy is freed and its mesentery is released up to the mesenteric root, above the duodenum. The J-pouch is constructed out of the abdomen by folding the distal ileum with two arms of 8–12 cm, according to patient’s age. A side-­ Milestone 15.4  Rectal stump linear stapler division

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P. Palazón and X. Tarrado

placed next to the pouch anal anastomosis. The posterior mesenteric defect should be closed to avoid an internal hernia. A protective loop ileostomy is created, avoiding any tension on the pouch.

15.5 Postoperative Care

Milestone 15.5  Ileal J-pouch construction

A nasogastric tube and prophylactic antibiotics are maintained for 24 h. A longer course of antibiotic therapy is used in case of contamination or peritonitis. Total parenteral ­nutrition postoperatively is administrated in selected cases with a poor clinical and nutritional status. Feeding is started once bowel movements appear, usually 24 h after the surgery. Patients can be discharged generally in 4–5 days. Although removing the entire colon and rectum will cure the disease allowing them to stop medical treatment, follow­up is necessary to monitor weight, nutritional status, continence and stool output. Postoperative complications include anastomotic leak and stenosis of IPAA, wound infection, pelvic abscess, cuffitis and pouchitis.

15.6 Pearls/Tips & Tricks

Milestone 15.6  Ileal pouch-anal circular stapled anastomosis

to-­side anastomosis dividing the common wall is performed with a 60  mm linear stapler introduced through an apical enterotomy (Milestone 15.5). The anvil of the circular stapling device is inserted into the enterotomy at the apex of the pouch and secured using a purse-string suture. Be sure that the future end-to-end stapling does not impinge on the mesentery of the ileum. The J-pouch is introduced into the abdominal cavity, the ileostomy incision is partially closed and capnoperitoneum is again started. The pouch is placed down in the pelvis taking care to maintain proper orientation and avoid any twisting of the mesentery. The circular stapler is inserted through the anal canal and gently advanced into the closed stump. Make sure that the anvil of the circular stapler does not join the stapler line of the rectal stump in order to avoid overstapling. Once the circular stapler is fired and ileoanal anastomosis is completed (Milestone 15.6), two complete tissue donuts should be identified in the device. Air or fluid instillation test is done to rule out leakage. A drain is

1. Pulling the transverse colon up to the stomach allows a better visualization to dissect transverse mesocolon. 2. Dividing the rectal stump during proctectomy is easier with smaller devices. A 45 mm device allows its introduction down in the pelvis and the complete division of the rectal stump with one or two firings. Longer loads are hard to introduce in the pelvic ring and they cut too longitudinally the stump. Shorter cartridges are easily introduced but the number of loads needed increases and the chance for leakages too. 3. When creating the pouch, it should be confirmed that it can be moved down to the pubis in order to ensure an adequate anastomosis. Dissecting de mesentery up to its root, and making serial small windows in the highest tension axis of the mesentery help achieving a tension-free ileal pouch-anal anastomosis. 4. It is preferable to avoid having the circular staple device crossing the stapled line in the stump of the rectum, as this may lead to an increased risk of anastomotic leak. 5. Placing a drain into the pelvis near the pouch is recommended. There is often a large volume of postoperative intraabdominal fluid because of the dissection of the lymphatics in the mesorectum. In addition, a leak can be identified and contained early.

15  Laparoscopic Management in Ulcerative Colitis: Staged Proctocolectomy with Ileal Pouch-Anal Anastomosis

15.7 Pitfalls & Ways to Avoid 1. As ureters lie below the ascending and descending colon and aside to the sigmoid and rectum, they can be injured during the dissection (especially in emergencies or reoperations). Identifying both ureters during proctocolectomy always has to be kept in mind. 2. Dissecting deeply in the transverse mesocolon can result in duodenum injury. Releasing the hepatic flexure of the colon first and close-to-colon division of the mesocolon help avoiding this hazard. 3. A long pouch increases the risk of pouchitis because of retained stools, and small pouches have small capacity resulting in multiple daily bowel movements. Pouch size has to be adjusted to the patient size. 4. The vagina is vulnerable to injury during proctectomy, and also pouch-vaginal fistula could be created with the circular stapled anastomosis if it incorporates its posterior wall. In males, the seminal vesicles and prostate are similarly at risk. Dissecting the mesorectum close to the rectal wall and careful inspection before firing the circular stapler is advisable. 5. When performing the IPAA twisting the ileal limb inadvertently can result in obstructive symptoms. The lack of twisting before firing the circular stapler should be reassessed. 6. The IPAA leaves a space behind the ileal limb that could allow the small bowel to slip through and cause an inter-

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nal hernia. Reperitonealization is tiring at this point of the procedure but highly recommendable.

References 1. Cabrera JM, Sato TT. Medical and surgical management of pediatric ulcerative colitis. Clin Colon Rectal Surg. 2018;31(2):71–9. 2. Ryan DP, Doody DP. Surgical options in the treatment of ulcerative colitis. Semin Pediatr Surg. 2017;26(6):379–83. 3. Ceriati E, De Peppo F, Rivosecchi M. Role of surgery in pediatric ulcerative colitis. Pediatr Surg Int. 2013;29:1231–41. 4. Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, Martin de Carpi J, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos KH, Croft N, Navas-López VM, Wilson DC, Lawrence S, Russell RK. Management of paediatric ulcerative colitis, Part 1: ambulatory care-an evidence-based Guideline from the European Crohn’s and Colitis Organization and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2018;67(2):257–91. 5. Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, Martin de Carpi J, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos KH, Croft N, Navas-López VM, Wilson DC, Lawrence S, Russell RK. Management of paediatric ulcerative colitis, Part 2: acute severe colitis-an evidence-based consensus Guideline from the European Crohn’s and Colitis Organization and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2018;67(2):292–310. 6. Mattioli G, Guida E, Pini-Prato A, Avanzini S, Rossi V, Barabino A, Coran AG, Jasonni V. Technical considerations in children undergoing laparoscopic ileal-J-pouch anorectal anastomosis for ulcerative colitis. Pediatr Surg Int. 2012;28:351–6.

Laparoscopic Approach in Anorectal Malformations

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Alejandra Vilanova-Sánchez, Richard J. Wood, Carlos A. Reck-Burneo, Devin R. Halleran, and Marc A. Levitt

16.1 I ndication for Laparoscopic Approach to Hirschsprung Disease The majority of ARM can be repaired through a posterior sagittal incision. However, there are some types of anorectal malformations which need an abdominal approach in order to detach the rectum from the urinary tract in males or from the vagina in girls [1]. Those ARMs which benefit from laparoscopy include high prostatic or bladder neck fistula in males and congenital high recto-vaginal fistula or cloacas with high rectum in girls [2]. Advantages of a laparoscopic-­assisted anorectal pull through include less surgical trauma compared with an abdominal laparotomy incision, excellent visualization of the fistula and gynecologic anatomy, and theoretically less dissection of the levator ani and sphincter complex [3].

16.2 Preoperative Workup and Considerations All patients must have a complete VACTERL (vertebral, anal, cardiac, tracheo-esophageal, renal, and limb) screening work-up. This includes: Chest X-ray and abdominal X-ray, Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_16. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. A. Vilanova-Sánchez (*) University Hospital La Paz, Madrid, Spain e-mail: [email protected] R. J. Wood · D. R. Halleran Nationwide Children’s Hospital, Columbus, OH, USA C. A. Reck-Burneo Medical University of Vienna - Dept. of Pediatric Surgery, Vienna, Austria M. A. Levitt Children’s National Hospital, Washington, DC, USA e-mail: [email protected]

AP and lateral sacrum X-ray, spinal U/S or MRI, echocardiogram, and renal U/S.  Also, urological assessment is very important and ideally performed by a pediatric urologist or pediatric surgeon with urologic expertise [4]. Before the procedure, a high-pressure distal colostogram should be completed in order to identify position and length of the distal rectum. This study will help the surgeon decide whether the patient requires a posterior sagittal approach only, or one combined with a laparoscopic/abdominal assisted pull through [5]. No bowel preparation is needed as all the patients have a sigmoidostomy.

16.3 Anesthetic Considerations Laparoscopic assisted PSARP is performed under general endotracheal anesthesia. Intraoperative bleeding is rare, but having blood available is advisable. Before starting the abdominal part, stimulation and marking of the sphincter complex is performed without muscle relaxation. At least 2 peripheral intravenous catheters should be available. Hypothermia resulting from the total body preparation hypothermia should be avoided.

16.4 Operative Technique 16.4.1 Equipment • • • • • •

3 (4 mm) trocars 1 (5 mm) 30° laparoscope 2 atraumatic graspers (3 mm) endosealer 1 (3 mm) hook monopolar cautery 2/0 monofilament non-absorbable suture for the bladder stay suture • 2/0 monofilament absorbable preloaded endoloop • 4 or 5/0 absorbable braided suture for the coloanal anastomosis.

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_16

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Coude-tip urethral catheter Peripheral nerve stimulator Hegar dilators Marking pen for the sphincter complex Olsen tip/Colorado tip electrocautery Forceps and needle driver for open surgery

patient, at the patient right shoulder. The monitor is at the left lower side of the bed as shown in Fig. 16.1. The assistant stands to the left upper side of the patient. The scrub nurse is positioned in the right lower side of the patient, in line with the surgeon. For the transanal portion of the case, the same supine position with the legs elevated is maintained. The surgeon stands to the right side of the patient and the assistant to the left side. The scrub nurse and the table remain at the same site as it was for the abdominal dissection.

16.4.2 Positioning For the abdominal part, the patient is positioned supine in the middle of the table and a total body preparation is performed from the nipples to the toes. Two people are needed to complete the prep, as one person preps the patient while the other (wearing sterile gloves) lifts the patient. Once the entire patient is prepped from the toes to the nipples, the prepping person pulls the ¾ sheet out from under patient and the scrub nurse places sterile ¾ sheet under patient. Then the legs are laid down. The patient is then placed through the circular opening of a large sterile drape. The legs are wrapped in sterile dressing (sterile cotton and a transparent sterile adhesive film) up to the buttock crease. The sterile transparent slim should have a “toe flap” (so that it can later have a clamp on it without crushing the toes or falling off). The surgeon stands to the right upper part of the

Fig. 16.1  Operating room positioning

16.4.3 Trocar Placement A 5 mm 30° camera and 4 mm trocars (2 or 3) are utilized as the instruments (5 mm trocars are also accepted). Hook electrocautery and a 3  mm endoscopic vessel sealing device are utilized to avoid thermal spread when approaching the bladder/vagina. The right upper quadrant port is used for the camera access. The right lower quadrant port is for the surgeon’s right hand and the umbilicus is for the surgeon’s left hand. A 3 mm port in the mid left abdomen is to help with the fistula ligation and is useful to retract the rectosigmoid.

Legend

Patient

Legend Working trocar

Monitor Surgeon Assistant Scrub nurse Instrument table

Endoscope trocar Accessory trocar

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16.5 Operative Milestones (Milestones 16.1, 16.2, 16.3, 16.4, and 16.5) Milestone 16.1  Bladder fixation and rectal dissection. The first step is to fix the bladder to the anterior abdominal wall with a transcutaneous stay suture to have better exposure of the pelvis. Depending on bladder anatomy, this is not always necessary (a). The distal rectum is then mobilized using thermal dissection in a circumferential fashion (b) (Video 16.1 16_VAPE_ARM_ milestones_om20200501). (▸ https://doi.org/10.1007/000-2v9)

a

b Transcutaneous suture

Bladder

Bladder Rectum Rectum

Milestone 16.2 Fistula ligation. Once the fistula is dissected circumferentially, at the point of maximal tapering near the bladder, the fistula is divided (a). The distal fistula should be dissected to the size whereby a 3 mm grasper can go all the way across it. The bladder side is secured with a grasper and a pre-loaded endoloop closes the fistula site (b)

Milestone 16.3 Mini-­ posterior sagittal incision. Once there is enough rectal length, the patient’s legs can be elevated (a). There is no need for prone positioning. The muscle complex is defined with the nerve stimulator, and a limited posterior sagittal incision is made (b)

a

Recto-bladder fistula

b Fistula ligated

Rectum

a

Rectum

b

Patient in supine position with legs up

Limited sagittal incision

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a

16.6 Postoperative Care

Fistula ligated

It is recommend to avoid any buttock spreading the first 2  weeks following surgery. A nasogastric tube is not required in the postoperative period. Full oral feeds can be initiated immediately following surgery as the child has a colostomy. Postoperative antibiotics should be continued for 48 hours or as per local protocol. The Coude catheter is kept in place for 1 week in patients with recto-bladder or recto-urethral fistula. In females with rectovaginal fistula, it is kept in for 1–2 days. In cloacas, it will determined by the urethral manipulation required during the procedure after the laparoscopic dissection. The catheter can be placed between two diapers to allow the infant more comfort and mobility. Patients are usually discharged on the second to third postoperative day. In the postoperative period and upon discharge, the wound should be washed with soap and water, wiping should be avoided and the area should be patted dry. The patient will need to be examined in clinic 2 weeks after surgery to assess the need for anal dilations. Once the ideal Hegar size for age is reached the colostomy can be closed, usually 2–3  months after the procedure (Table 16.1).

Blunt dissection reaching the peritoneal reflection

b

View from the outside

c

Table 16.1  Hegar size according to age

Dissected rectum being pulled trough

Age Newborn-4 months 4–8 months 8–12 months 1–3 years 3–12 years Older than 12

Hegar size 12 13 14 15 16 17

Milestone 16.4  Fistula pull-through. The incision is opened with the electrocautery and with blunt dissection in order to reach the peritoneal reflection (a). The rectum is then pulled through the limited posterial sagittal incision (b) Milestone 16.5 Anoplasty and closing of the posterior sagittal incision. We then tack the muscles to the pulled through rectum to avoid prolapse and perform an anoplasty with 16 interrupted stitches (a). The posterior sagittal incision is closed (b)

a

b Tacking the rectum to the muscles

16  Laparoscopic Approach in Anorectal Malformations

16.7 Pearls/Tips & Tricks 1. In the lateral view of the high pressure colostogram, draw a line from the tip of the coccyx to the very next structure one would find via a posterior sagittal approach. If the structure on the contrast enema is the rectum then the rectum is reachable from below. If not, a laparoscopic approach is preferred. 2. In select cases of recto-bladder fistula, if the bladder anatomy of the patient blocks the view of the distal dissection of the rectum going into the bladder, a transcutaneous stitch to elevate the bladder improves posterior bladder visualization in the pelvis. 3. Identify the vas deferens and ureters during pelvic dissection and avoid injury to these structures.

16.8 Pitfalls & Ways to Avoid 1. The segment of rectum pulled through can be misplaced outside of the sphincter mechanism and the rectum is likely to prolapse if this complication is not intentionally avoided with several key steps. To avoid this complication, a small posterior sagital incision should be made.

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This way, the rectum can be tacked to the muscles and placed right at the center of the sphincter complex. 2. If the rectum pulled through is not well dissected, the anastomosis will be done under tension and the anoplasty can have dehiscence and stricture. Full thickness dissection of the distal rectum should be done in order to gain length.

References 1. Bischoff A, Peña A, Levitt MA.  Laparoscopic-assisted PSARP  the advantages of combining both techniques for the treatment of anorectal malformations with recto-bladderneck or high prostatic fistulas. J Pediatr Surg. 2013;48:367–71. 2. Bischoff A, Levitt MA, Peña A. Laparoscopy and its use in the repair of anorectal malformations. J Pediatr Surg. 2011;46:1609–17. 3. Rentea RM, Halleran DR, Wood RJ, Levitt MA.  The role of laparoscopy in anorectal malformations. Eur J Pediatr Surg. 2020;30:156–63. 4. Minneci PC, Kabre RS, Mak GZ, Halleran DR, Cooper JN, Afrazi A, et  al. Screening practices and associated anomalies in infants with anorectal malformations: results from the Midwest pediatric surgery consortium. J Pediatr Surg. 2018;53:1163–7. 5. Gross GW, Wolfson PJ, Pena A. Augmented-pressure colostogram in imperforate anus with fistula. Pediatr Radiol. 1991;21:560–2.

Laparoscopic Approach to Hirschsprung Disease

17

Alejandra Vilanova-Sánchez, Richard J. Wood, Carlos A. Reck-Burneo, Devin R. Halleran, and Marc A. Levitt

17.1 I ndication for Laparoscopic Approach to Hirschsprung Disease

17.2 Preoperative Workup and Considerations

Hirschprung Disease (HD) is relatively common in children. Surgical techniques aim to remove the aganglionic bowel, to reconstruct pull through of the healthy bowel to the anal canal, and to preserve the continence mechanism [1]. The vast majority of cases of HD have a transition zone (TZ) in the rectosigmoid (80%) [2]. However in some the TZ extends towards the proximal colon even reaching, in some cases, the small bowel. For most of the patients with HD a laparoscopic approach could be performed, specially those patients with no previous laparotomy and no ostomy in place are the ideal candidates for a laparoscopic-assisted approach. The laparoscopic-­ assisted approach has the advantage to allow intestinal biopsies earlier during the operation compare with transanal pull-through. This could optimize the time for perioperative histological examination to define the level of aganglionosis and simplify the preparation of the colon for pull-through that would be performed through the anal canal, being technically more demanding and possibly requiring anal sphincter stretching [3, 4].

The gold standard for diagnosing HD is a rectal biopsy confirming the absence of ganglion cells and the presence of hypertrophic nerves [3]. To predict the level of the transition zone (TZ) a contrast enema (CE) is used, but this test has only 80% of sensitivity of predicting the segment of aganglionic bowel [5]. For those cases where the level of the TZ is not clear on the contrast enema, or when the newborn does not do well with rectal irrigations, an ostomy may be necessary. For the primary pull through, the abdominal part of the procedure is now ideally done using a laparoscopic approach. However, if the patient has a previous laparotomy with an ostomy in place, we prefer to perform a laparotomy instead, essentially via the same incision required to close the stoma. Before the pull through, the family should be taught how to perform irrigations just in case the patient needs them after the procedure. All patients must have a complete mechanical bowel preparation before the procedure with both oral and IV antibiotics and irrigations until the bowel is clean.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_17. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. A. Vilanova-Sánchez (*) University Hospital La Paz, Madrid, Spain e-mail: [email protected] R. J. Wood · D. R. Halleran Nationwide Children’s Hospital, Columbus, OH, USA C. A. Reck-Burneo Medical University of Vienna - Dept. of Pediatric Surgery, Vienna, Austria M. A. Levitt Children’s National Hospital, Washington, DC, USA e-mail: [email protected]

17.3 Anesthetic Considerations A Laparoscopic assisted Pull-through for HD is performed under general endotracheal anesthesia. Intraoperative bleeding is rare, but having blood available is advisable. During the transanal dissection, deep muscle relaxation is mandatory in order to avoid sphincter damage when placing the retractor hooks. A pathologist needs to be aware of the procedure and ready to perform the frozen section biopsy analyses. At least 2 peripheral intravenous catheters should be available. Particularly in light of the total body preparation, hypothermia should be avoided by ambient room heating.

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17.4 Operative Technique 17.4.1 Equipment • • • • • • • • • • •

4 (4 mm) trocars 1 (3 mm) 30° laparoscope 2 or 3 atraumatic graspers (3 mm) Maryland dissector 1 (3 mm) hook monopolar cautery 4 or 5/0 absorbable braided suture for the coloanal anastomosis. Sharp hook circular retractor (Lone star ring) Eight lone star pins Foley catheter Olsen tip/Colorado tip electrocautery Forceps and needle driver for open surgery

17.4.2 Positioning For the abdominal part, the patient is positioned supine in the middle of the table and a total body preparation is performed from the nipples to the toes. Two people are needed to complete the prep, as one person preps the patient while the other (wearing sterile gloves) lifts the patient. Once the entire patient is prepped from the toes to the nipples, the prepping person pulls the ¾ sheet out from under patient and the scrub nurse places a sterile ¾ sheet under patient. Subsequently, the legs are laid down. The patient is then placed through the circular part of a large sterile drape. The legs are wrapped in sterile dressings (sterile cotton and a transparent adhesive film) up to the mid-thigh. The sterile transparent film dressing should have a “toe flap” (so that it can later have a clamp on it without crushing the toes or falling off). During the procedure: The surgeon stands at the right upper side of the patient at the shoulder in front of the monitor, which is at the foot and end of the bed. The assistant is on the left upper side holding the camera and graspers during

Fig. 17.1  Laparoscopic Set up for laparoscopic assisted pull-through

the sigmoid dissection. The scrub nurse is on the left lower side of the table in line with the surgeon (Fig. 17.1). For the transanal part: Same supine position with the legs elevated. The surgeon will stand to the right side of the patient and the assistant to the left side. The scrub nurse and the table will remain at the same location as it was for the abdominal dissection.

17.4.3 Trocar Placement We start with the laparoscopic portion of the case inserting a 4 mm trocar in the umbilicus and another 4 mm in the right upper quadrant. The peritoneum is insufflated using pressure of 8–10  mmHg and a flow of 1–2  l/min. After receiving the pathologist report, we then insert a left upper quadrant and right lower quadrant 4  mm ports to start the sigmoid arcade dissection. The right upper quadrant port is for the camera, and the right lower quadrant port is for the surgeon’s right hand. The umbilical port is for the surgeon’s left hand and the left upper quadrant is the assisting port. Once the pelvic dissection is complete, we remove the laparoscopic ports and elevate the patients legs up to start the transanal dissection.

17.4.4 Operative Milestones 1. Confirming the level of the TZ: If colonic mapping was not done previously we need to confirm the level of the TZ to make sure the PT will be feasible laparoscopically. The algorithm in Fig. 17.2 helps with decision-making at this point. This biopsy can be done through the umbilical port and a full thickness biopsy taken at the level of the potential TZ on the CE.  A full thickness biopsy assures assessment of the submucosa. It must be remembered that the seromuscular

Legend Patient Legend Monitor Surgeon Assistant Scrub nurse Instrument table

Working trocar Endoscope trocar Accessory trocar

17  Laparoscopic Approach to Hirschsprung Disease Fig. 17.2  Algorithm for laparoscopic assisted pull through based on the frozen section results and patient’s colonic arcade

91 Laparoscopic assisted pull-through Ganglion cells present in frozen section

Sigmoid colon

Pull-through

Splenic flexure or proximal

Left colon

No need to mobilize splenic flexure

Need to mobilize splenic flexure

Pull-through

Need to take down middle colic? No

Colonic mapping and ileostomy

Yes Right marginal present

No right marginal present

Milestone 17.1 Leveling biopsy through the umbilicus (Video 17.1 17_VAPE_Hirschsprung_ milestones_om20200501). (▸ https://doi.org/10.1007/000-2va)

Theoretical transition zone

Transumbilical full thickness biopsy

Milestone 17.2 Sigmoid arcade dissection Proximal Sigmoid

Mesenteric window

Biopsy site Distal sigmoid

layer can have ganglion cells but the submucosal layer could have hypertrophic nerves, consistent with TZ. If the surgeon prefers to do a seromuscular biopsy only, then prior to doing the anastomosis, a full thickness should be done to confirm ganglionated bowel at all layers. If the TZ is in the left colon and the splenic flexure needs to be mobilized, or the TZ is proximal to the splenic flexure, our preference is an initial ileostomy with colonic mapping. An open procedure is needed if derotation of the right colon is required at the time of the pull-through (Milestone 17.1). We select the biopsy site based on the contrast enema and macroscopic transition zone and pull it out through the umbilical port. Once the full thickness biopsy is taken we

close the defect with interrupted stitches and put the bowel back into the abdomen (Milestone 17.2). We first open a mesenteric window at the level of our previous biopsy and start the dissection with thermal energy. The IMA arcade to the sigmoid is carefully preserved (Milestone 17.3). Once we reach the rectum we start the dissection in a Swenson type-fashion, right on the rectal wall. With the dissection of the distal rectum completed from the abdomen, we place the patient’s legs up to begin the transanal dissection (Milestone 17.4). With the patient in supine position we place the legs up. We identify the dentate line and hide it with the hook retrac-

92 Milestone 17.3 Rectal dissection in a Swenson fashion type

A. Vilanova-Sánchez et al. Peritoneal reflection

Dissected mesentery

Milestone 17.4 Transanal dissection Dentate line marked in purple

Milestone 17.5 Swenson type dissection

Swenson plane dissection

Dentate line hidden with the hooks

Anastomosis site 5 cm proximal to the biopsy

Biopsy site Once we are able to enter the peritoneum, we can see the branches of the sigmoid mesentery

tors. We create circumferential traction with silk stitches placed 1 cm proximal to the dentate line and begin the dissection (Milestone 17.5). Once we are able to enter the peritoneum, we can see the branches of the sigmoid mesentery ligated from our previous dissection and or prior biopsy with normal ganglion cells and no hypertrophic nerves. We then select the segment for our first layer anastomosis from muscle to colonic serosa approximately 5  cm proximal to the biopsy in order to prevent transition zone anastomosis (Milestone 17.6). We replace the retractor pins to show the previously hidden mucosal edge and we then complete our second layer of the anastomosis at the level of the previous resection utilizing 16 well-placed interrupted Vicryl sutures, from mucosa to mucosa.

Colo-anal anastomosis

Milestone 17.6  Colo-anal anastomosis

17  Laparoscopic Approach to Hirschsprung Disease

17.5 Postoperative Care

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17.7 Pitfalls & Ways to Avoid

A nasogastric tube is left in place and drained to gravity. 1. The anal canal is very short in babies and the dentate line is Once the output has decreased below 10  mL/kg/day the very close to the anal verge. In order to avoid an injury to this tube can be removed and the patient started on clear liquid important structure for continence it should be protected and advanced to normal feeds for their age. Once the with the sharp retractor pins. This way, the dissection and the patient is stooling and eating normally the patient can be anastomosis is always performed above the dentate line. discharge home. No anal dilation is needed after the pull through. If the patient presents at some point with difficulties passing stools, irrigations with 0.9% sodium chloride References solution is initiated. 1. Levitt MA, Hamrick MC, Eradi B, Bischoff A, Hall J, Peña The anus is inspected in the clinic to check the colo-­ A.  Transanal, full-thickness, Swenson-like approach for anastomosis 2–4 weeks after the pull through. Hirschsprung disease. J Pediatr Surg. 2013;48:2289–95.

17.6 Pearls/Tips & Tricks 1. Do not start the colonic dissection until having the pathologist has confirmed the level of the ganglionic bowel following the algorithm show in Fig. 17.1. 2. Complete the majority of the pelvic dissection laparoscopically to avoid extra dissection and overstretching of the sphincter transanally. 3. Do not twist the pull through. Once you start the transanal dissection put a stay suture in the anterior part of the rectum to avoid twisting when doing the anastomosis and pass a Foley catheter up to the pull through to confirm the absence of a twist.

2. Swenson O, Sherman JO, Fisher JH. Diagnosis of congenital megacolon: an analysis of 501 patients. J Pediatr Surg. 1973;8:587–94. 3. Iacusso C, Leonelli L, Valfrè L, Conforti A, Fusaro F, Iacobelli BD, et  al. Minimally invasive techniques for Hirschsprung disease. J Laparoendosc Adv Surg Tech. 2019;29(12):2019. 4. Thomson D, Allin B, Long A-M, Bradnock T, Walker G, Knight M.  Laparoscopic assistance for primary transanal pull-through in Hirschsprung’s disease: a systematic review and meta-analysis. BMJ Open. 2015;5:e006063. 5. Martucciello G, Prato AP, Puri P.  Controversies concerning diagnostic guidelines for anomalies of the enteric nervous system: a report from the fourth international symposium on Hirschsprung’s disease and related neurocristopathies. J Pediatr. 2005; https://doi. org/10.1016/j.jpedsurg.2005.07.053.

Part IV Hepatobiliary

Laparoscopic Cholecystectomy

18

Nadia Guardado, Trenton Burgess, and Lena Perger

18.1 Indications for Laparoscopic Approach to Cholecystectomy The indications for open or laparoscopic cholecystectomy are the same. Multiple randomized controlled trials demonstrate that when compared to open cholecystectomy, laparoscopic cholecystectomy reduces pain and disability, does not have increased morbidity or mortality, is cosmetically superior, and is less or equally costly as open cholecystectomy [1–3].

18.2 Preoperative Workup and Considerations Cholecystectomy is indicated in symptomatic cholelithiasis/ chronic cholecystitis, acute cholecystitis, and after resolution of gallstone pancreatitis, choledocholithiasis and cholangitis [1, 3]. Ultrasound is the gold standard for diagnosis of gallstones. HIDA scan showing non-filling gallbladder, along with US showing gallbladder wall thickening and pericholecystic fluid, are diagnostic of acute cholecystitis, which should be treated with antibiotics and early cholecystectomy within 72 h. Laboratory work-up should include a complete blood count, liver function tests and amylase/lipase. Biliary dyskinesia is a controversial indication for cholecystectomy. Relief of symptoms may or may not be achieved, and even if initially successful, long term results are inferior to initial short term success [4]. One dose of perioperative antibiotics (cefazolin) is given. Orogastric tube may be placed to decom-

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_18. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App.

press the stomach, but it is not required. Urinary catheter insertion is not required.

18.3 Anesthetic Considerations Laparoscopic cholecystectomy is performed under general anesthesia and endotracheal intubation. An elective operation is usually performed in an ambulatory setting for otherwise healthy children.

18.4 Operative Technique 18.4.1 Equipment • One 12-mm trocar to accommodate retrieval bag and specimen extraction • Three 5-mm trocars • Two atraumatic graspers • One Maryland grasper • Hook cautery • Endoscopic clips • Endoscopic scissors • 10-mm endoscopic specimen retrieval bag

18.4.2 Positioning Supine positioning with arms tucked by patient’s side, slight reverse Trendelenburg and right side up if needed to improve gallbladder exposure. Operating surgeon stands on the left side of the patient and the first assistant on the right side of the patient. Two monitors are placed, one by each shoulder (Fig. 18.1). The security belt should be placed at the hips or below to allow full exposure of the abdomen.

N. Guardado · T. Burgess · L. Perger (*) University of New Mexico Health Sciences Center, Albuquerque, NM, USA © Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_18

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Fig. 18.1  Positioning of patient, surgeons and monitors

Legend

Patient

Monitor Surgeon Assistant Scrub nurse Instrument table

Legend Working trocar

the diaphragm by the assistant who also holds the camera. The surgeon uses an atraumatic grasper in left hand to manipulate the infundibulum and retract it laterally to expose the triangle of Calot. In the right hand, a Maryland dissector and hook cautery are used interchangeably to dissect out the gallbladder infundibulum, cystic duct, cystic artery and develop a window to achieve the critical view of safety.

Endoscope trocar

18.4.4 Operative Milestones

Fig. 18.2  Trocar placement

18.4.3 Trocar Placement Trocars are placed as shown in Fig. 18.2. A 12-mm trocar can be placed either at the umbilicus or in the epigastrium. A 5-mm 30° scope is introduced through the umbilicus. A 5-mm locking grasper is placed through the most lateral port and used to grasp the gallbladder at the fundus and retract it toward

The gallbladder is grasped at the fundus and retracted toward the diaphragm (Milestone 18.1). Any adhesions are taken down bluntly or with cautery until the infundibulum is exposed. A 5-mm atraumatic grasper is used to retract the infundibulum of the gallbladder laterally to expose the triangle of Calot (Milestone 18.2). Maryland dissector and hook cautery are used to open the overlying peritoneum and define the cystic duct. In case of severe inflammation, careful dissection layer by layer is required until the gallbladder wall is identified along with the junction of the gallbladder and the cystic duct. Staying right on the gallbladder wall is the safest principle if anatomy is obscured by inflammation and fat. We do not make specific attempts to identify the main trunk of the cystic artery on its course toward the gallbladder,

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Milestone 18.3  Critical view of safety Milestone 18.1  Cephalad retraction of gallbladder fundus. (Video 18.1 Laparoscopic Cholecystectomy VAPES chapter_20200405om). (▸ https://doi.org/10.1007/000-2vb)

Milestone 18.4  Clipping of the cystic duct

Milestone 18.2  Exposure of triangle of Calot

instead we divide its branches along the gallbladder wall with hook cautery. A window is developed behind the cystic duct by gentle spreading with the Maryland dissector until the critical view of safety is established. The critical view of safety consists of a clear identification of the inferior edge of the gallbladder superiorly, cystic duct laterally, and visible liver surface through the window between them, assuring that the tubular structure thought to be the cystic duct is clearly entering the gallbladder only (Milestone 18.3). The cystic artery can be a part of the critical view, being a pulsating tubular structure medially to the cystic duct, also entering the gallbladder only, with liver surface visible on both sides of it. If the branches of the cystic artery are divided along the

gallbladder wall while dissecting out the infundibulum, the artery will already be away from the gallbladder at this point in the operation, coursing through the fatty tissue medially and out of the operating field. Of note, the common bile duct and common hepatic duct do not need to be exposed. Once the critical view of safety is achieved, clips are placed on the cystic duct (Milestone 18.4), and artery (optional, if the artery has been dissected out), one on the specimen side and two on the staying side. Endoscopic scissors are used to transect these two structures between the clips. Next, the gallbladder is dissected off the liver bed using hook cautery. The specimen is placed in an endoscopic bag and removed through the 12-mm port. Irrigation and suction is used optionally if there was spillage of bile. If any gallstones are spilled, it is of great importance to retrieve them all to prevent subsequent abscess and fistula formation. The fascia at the 12-mm port site is closed using a figure of 8 stitch, with 0 Vicryl suture. The skin edges on all port sites are approximated using 4-0 Monocryl.

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18.5 Postoperative Care The procedure may be performed in an outpatient setting. Patients may return to normal activities with a 2 week restriction of strenuous or sports activities.

18.6 Pearls/Tips & Tricks 1. Lateral retraction is key for adequate visualization of the cystic duct and cystic artery 2. If structures in the triangle of Calot are tightly fused due to inflammation, and anatomy is not safely identifiable, entering the gallbladder and performing a partial cholecystectomy is the safest option with good outcomes. 3. In case of aberrant anatomy, consider intraoperative cholangiogram before dividing any structures. 4. The common hepatic and common bile ducts should not be dissected out.

18.7 Pitfalls & Ways to Avoid 1. Injury to common hepatic duct, common bile duct and right hepatic artery can be avoided by staying close to the gallbladder and cystic duct during dissection.

N. Guardado et al.

2. The cystic duct can be divided close to the gallbladder, no need to attempt dissection along its length toward the common bile duct and risk injury to it. 3. Careful blunt dissection and use of cautery on vascular adhesions is important to minimize bleeding, which obscures visibility. 4. When dividing dissecting the gallbladder off the liver with hook cautery, adequate tension helps to avoid entering the liver or gallbladder during dissection.

References 1. NIH. National Institutes of Health consensus development conference statement on gallstones and laparoscopic cholecystectomy. Am J Surg. 1993 Apr;165(4):390–8. 2. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Eng J Med. 1991 Nov;324(16):1073–8. 3. St Peter SD, et al. Laparoscopic cholecystectomy in the pediatric population. J Laparoendosc Adv Surg Tech A. 2008 Feb;18(1):127–30. 4. Lacher M, et  al. Laparoscopic cholecystectomy for biliary dyskinesia in children: frequency increasing. J Pediatr Surg. 2013 Aug;48(8):1716–21.

Laparoscopic cholangiography and Liver Biopsy

19

Jessica Zagory and Samir Pandya

19.1 Indications for Laparoscopic Approach to Liver Biopsy Liver biopsy provides histopathologic diagnosis, as well as a method to track progression of fibrosis, in a variety of neonatal and pediatric liver diseases. Tissue can be obtained via one of three approaches: open, transcutaneous, and transvenous biopsy methods. In an era of evolving minimally invasive techniques, laparoscopic liver biopsy is gaining traction. Studies have used laparoscopic guided cholecystocholangiography and liver biopsy in neonates in their first few days of life. Pediatric liver diseases typically present with persistent jaundice, and their underlying diagnoses include cholestasis, biliary atresia (BA), metabolic disorders, viral hepatitis, autoimmune hepatitis, fatty liver disease, and drug-induced liver injury. Liver biopsies are also used in monitoring fibrosis in the transplanted liver and aiding in the diagnosis of a liver mass. The above differential is narrowed with labs and imaging, but the gold standard of tissue diagnosis is required to proceed with treatment.

19.2 Preoperative Workup and Considerations In the neonatal and pediatric population, persistent hyperbilirubinemia triggers a laboratory workup including hepatitis panel, fractionated bilirubin, and coagulation profiles. This is Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_19. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. J. Zagory · S. Pandya (*) Division of Pediatric Surgery, UT Southwestern Medical Center, Dallas, TX, USA e-mail: [email protected]

often followed by imaging with an abdominal ultrasound. In cases of liver masses, a computed tomography (CT) or magnetic resonance imaging (MRI) may further characterize the mass. When there is concern for biliary atresia, a hepatobiliary dimethyl-iminodiacetic acid (HIDA) scan is obtained. If test results support our suspicion, we may choose to proceed with a biopsy. In select institutions, the cholangiogram is obtained using an endoscopic retrograde cholangiopancreatography (ERCP).

19.3 Anesthetic Considerations In both the laparoscopic and open approach, general anesthesia is used. During laparoscopy, neonates may require lower insufflation pressures (8–10 mmHg) if at risk for reopening the left to right shunt. Adequate venous access should be obtained and perioperative antibiotics should be administered. Normothermia, normoglycemia, and judicious amounts of intravenous fluids should be used.

19.4 Operative Technique and Equipment 19.4.1 Equipment • • • • • • •

3 or 5 mm instruments and trocars 3 or 5 mm 30° laparoscope 3 or 5 mm Maryland dissector 3 or 5 mm atraumatic grasper 3 or 5 mm Metzenbaum scissors 3 or 5 mm hook monopolar cautery (grounding pad) 3-0 monofilament polydiaxonone suture (to suspend the gall bladder transabdominally) • 4F micropunture kit or: –– 18-gauge needle (to puncture the gallbladder transcutaneously) –– 0.038 glide wire

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102 Fig. 19.1  Positioning of patient, surgeons and monitors

J. Zagory and S. Pandya Legend

Patient

C - Arm

Monitor Surgeon Assistant Scrub nurse Instrument table

–– 14 or 16 gauge flexible cannula Extension tubing Three way stop-cock 10cc of 50% dilute iohexol contrast solution 30cc injectable saline Endopeanut/Kittner 4-0 polydiaxonone or polyglactin 910 suture (to close needle cholecystotomy) • 18-gauge core needle biopsy gun • • • • • •

Legend Working trocar Endoscope trocar * Percutaneous entry site

*

19.4.2 Positioning The patient is positioned supine frogleg-positioning at the foot end of the bed with one arm extended sideways and one tucked to the side. The surgeon stands at the foot end of the bed, the monitor is at the head of the bed in-line with surgeon and patient (Fig. 19.1). The assistant stands to the right side of the surgeon, the scrub nurse on the left. The abdomen is prepped and draped from the nipples to the symphysis. The C-arm will come in via the right side of the table with the monitor preferably being near the head of the table.

19.4.3 Trocar Placement The size of the ports typically depends on the age and size of the patient; 3 mm ports are preferred for infants and 5 mm ports in older children. The optical port is placed in the umbilicus. An appropriately sized 30-degree camera is inserted to inspect the abdomen, and two additional trocars are placed (one on each side of the navel) along the mid clavicular line at the level of the umbilicus or slightly higher (Fig. 19.2).

Fig. 19.2  Positioning of the trocars

19.4.4 Operative Milestones After placement of the trocars, the abdomen is explored to clearly visualize the patient’s visceral anatomy. In cases of BA where a gallbladder is not visualized, the surgeon may choose to forego the cholangiogram and proceed with the Kasai portoenterostomy by either an open or laparoscopic method. If a cholangiogram is required after the gallbladder is visualized, a 3-0 monofilament polydiaxonone suture is placed transcutaneously to the dome of the liver to suspend the gallbladder to the anterior abdominal wall (Milestone 19.1). Under direct vision, the gallbladder is percutaneously punctured with a needle (Milestone 19.2), a guidewire is inserted, and subsequently a 14- or 16-gauge flexible cannula is advanced into the gallbladder over the guidewire for the cholangiogram (Milestone 19.3). The cannula is connected to an extension tubing and three-way stopcock. Diluted water-soluble contrast (iohexol) is used for the cholangiogram (Milestone 19.4). In order to delineate the intrahepatic ducts, the distal common bile duct is laparoscopically occluded using direct pressure with a cotton applicator

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Milestone 19.1  Transcutaneous suspension of gall bladder (Video 19.1 Laparoscopic liver biopsy and intra-operative cholangiogram). (▸ https://doi.org/10.1007/000-2vc)

Milestone 19.4  Intraoperative cholangiogram

Milestone 19.2  Percutaneous access to fundus

After completing the cholangiogram, either a core or wedge liver biopsy is obtained by sampling from the anterior lip of the liver under direct laparoscopic vision (Milestone 19.7). Suction and cautery should be in place in case of bleeding. Core Biopsy Several devices exist to obtain a core biopsy. The authors recommend utilization of the device that is locally accessible and following the manufacturers guidelines for the procedure. This technique does not require the additional trocars be placed. Wedge Biopsy Two additional ports will need to be placed to facilitate this. A 1  cm3 wedge of liver parenchyma is obtained sharply. The  raw surface is cauterized extensively after obtaining the biopsy. Others describe using a biopsy forceps and using coagulation after sampling for hemostasis.

Milestone 19.3  Insertion of 4F sheath/angiocath over wire

(Milestone 19.5). Depending on the size of the patient, a cholangiogram catheter set can be used as well. The cholecystotomy is then closed using intracorporal suturing (Milestone 19.6).

19.5 Postoperative Care There are no restrictions to activity postoperatively.

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Milestone 19.6  Suture closure of cholecystostomy

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Milestone 19.7  Percutaneous core needle biopsy

Milestone 19.5 Atraumatic instrument compressing distal CBD

19.6 Pearls/Tips & Tricks 1. Using laparoscopic scissors or other sharp instruments avoids leaving a charred edge of the liver in your biopsy specimen 2. Hemostatic agents and cautery can be used in a focused fashion after biopsy 3. If a core needle technique is used, typically a minimum of two passes are needed to provide an adequate amount of tissue

19.7 Pitfalls & How to Avoid 1. Complications include hemorrhage, abdominal pain, injury to other organs in the abdomen, bile leak, and cardiopulmonary or neurologic effects related to general anesthesia. Meticulous laparoscopic technique that would be used under any other circumstance should be followed during what may be considered a minor procedure such as a liver biopsy.

2. An adequate sample is required; a preoperative conversation with the pathologist will help in ensuring that you obtain the necessary amount needed for diagnosis (Video 19.1).

References 1. Dezsofi A, Knisely AS.  Liver biopsy in children 2014: who, whom, what, when where, why? Clin Res Hepatol Gastroenterol. 2014;38:395–8. 2. Lee JYJ, Sullivan L, El Demellawy D, Nasr A. The value of preoperative liver biopsy in the diagnosis of extrahepatic biliary atresia: a systematic review and meta-analysis. J Ped Surg. 2016;51:753–61. 3. Mogahed EA, Mansy YA, Al Hawi Y, El-Sayed R, El-Raziky M, El-Karaksy H.  Blind percutaneous liver biopsy in infants and children: comparison of safety and efficacy of percussion technique and ultrasound assisted technique. Arab J Gastroenterol. 2016;17:168–75. 4. Schady DA, Finegold MJ. Contemporary evaluation of the pediatric liver biopsy. Gastroenterol Clin N Am. 2017;46:233–52. 5. Shreef K, Alhelal A.  Evaluation of the use of laparoscopic-­ guided cholecystocholangiography and liver biopsy in definitive diagnosis of neonatal cholestatic jaundice. Air J Paediatr Surg. 2016;13(4):181–4.

Laparoscopic Kasai Portoenterostomy for Biliary Atresia

20

Go Miyano, Hiroyuki Koga, and Atsuyuki Yamataka

20.1 Introduction

20.2 Preoperative Work-Up

After Morio Kasai reported his original hepatic portoenterostomy procedure [1] for biliary atresia (BA), the number of cases achieving jaundice clearance and long-term survival with the native liver increased to such an extent that his procedure, the Kasai portoenterostomy, came to be regarded as the procedure of choice for treating BA. Minimally invasive surgery has evolved significantly in the past few decades and the first laparoscopic portoenterostomy was performed by Esteves et al in 2002 [2]. Thereafter, several reports confirmed that the procedure was feasible and safe. However, some centers began reporting that outcome of laparoscopic portoenterostomy was worse than conventional open portoenterostomy [3], and that laparoscopic portoenterostomy was more a demonstration of technical prowess than a therapeutically superior procedure. Meanwhile, a video of Professor Kasai performing a hepatic portoenterostomy as an open procedure was being scrutinized by Atsuyuki Yamataka, one of the authors. In the video, he found important technical features, such as shallow transection of the biliary remnant and preservation of the fibrotic connective tissues connecting the right and left biliary remnants, that had lost importance in the current open procedure, but which could be performed laparoscopically. In 2009, he started performing laparoscopic portoenterostomy according to Kasai’s original technique, specifically including the technical features he noted in Kasai’s video [4, 5].

All infant patients should have parenteral vitamin K2 supplementation, bowel preparation should commence with oral antibiotics, and they should be nil by mouth (npo) for 24 h prior to surgery. Parenteral broad-spectrum antibiotics should be administered preoperatively.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_20. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. G. Miyano (*) · H. Koga · A. Yamataka Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan e-mail: [email protected]

20.3 Operative Technique 20.3.1 Equipment • • • • • • • • • • •

Multiple instrument access device 5 mm 0° or 30° laparoscope 3 or 5 mm Maryland dissector 3 or 5 mm atraumatic grasper 3 mm needle holder 3 or 5 mm Metzenbaum scissors 5 mm hook monopolar cautery 3 mm bipolar cautery 5 mm Ligasure device 5-0, 6-0 monofilament polydiaxone sutures Nathanson retractor

20.3.2 Positioning and Trocar Placement The patient is positioned at the foot of the operating table and the surgeon at the patient’s feet. A monitor is placed at the head of the operating table facing the surgeon (Fig. 20.1). A 30° 5  mm or 10  mm scope is inserted through a multiple instrument access port device placed in an intra-umbilical incision. Pneumoperitoneum is created with CO2 pressure at 8–10  mmHg, using a gas flow rate of 0.5–1.0  L/min. Additional ports are placed under direct vision; two 5  mm ports on both sides of the umbilicus for the surgeon’s right and left hands, and a 5  mm port more laterally for the

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_20

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Fig. 20.1  Operating room setup for laparoscopic Kasai

Legend

Patient

Monitor Surgeon Assistant Scrub nurse Instrument table

Legend Working trocar Endoscope trocar

Fig. 20.2  Trocar placement for laparoscopic Kasai

a­ ssistant to apply counter traction and/or for scissors to be used during transection of the remnant. Percutaneous stay sutures (SS) and a Nathanson retractor (N) are used to improve exposure (Fig. 20.2).

20.4 Operative Milestones The first step is creation of the Roux-en-Y limb. The ligament of Treitz is identified and 15 cm of jejunum distal to the ligament is exteriorized through the umbilical port site to create a Roux-en-Y jejunal loop extra-corporeally. Roux limbs are always customized and never created to be a fixed predetermined length such as, 30, 40, or 50 cm in length. The jejunum limb is passed through a retro-colic window to lie without tension at the porta hepatis, and the jejunojejunos-

Milestone 20.1  Meticulous dissection of the cystic duct and the mid-­ to-­distal biliary remnant is performed with hook diathermy, tissue forceps, and a sealing device (Video 20.1 VAPE_Go Miyano, (re) Kasai). (▸ https://doi.org/10.1007/000-2vd)

tomy should fit naturally into the splenic flexure after anastomosis. This is followed by dissection of the biliary remnant. Meticulous dissection of the cystic duct and the mid-to-distal biliary remnant is performed with hook diathermy, tissue forceps, and a sealing device (Milestone 20.1). The fibrotic distal remnant is clipped and transected at the level of the duodenum, elevated and dissection proceeds from the hepatic artery and portal vein to the porta hepatis. The level of transection of the biliary remnant is more akin to what Kasai reported in the past; not the extended modifications found commonly in descriptions of extended conventional open portoenterostomies (Milestone 20.2). Finally, the portoenterostomy is performed. An extracorporeal surgical knot and interrupted sutures for the anastomosis are placed between

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apparent clinical benefit, the patient should be actively considered for liver transplantation.

20.6 C  omparison to Open Kasai Portoenterostomy 20.6.1 Meticulous Dissection and Precise Transection of the Biliary Remnant

Milestone 20.2  The level of transection of the biliary remnant is more akin to what Kasai reported in the past; not the extended modifications found commonly in descriptions of extended conventional open portoenterostomies

Although, the level of transection of the remnant ought to be the same for both laparoscopic and open Kasai techniques, the open technique may enable more meticulous transection and more precise design of the line of transection. The remnant fibrous mass is retracted caudally using stay sutures, and transected using a scalpel that initially should be used gingerly by chipping only the outer surface circumferentially, thus allowing the inner tissue of the remnant mass to be exposed or begin to protrude. Chipping is continued enough to ensure that tissue from the remnant continues to protrude and is transected. This kind of meticulous dissection and precise transection cannot be performed laparoscopically, so a laparoscopic Kasai should only be attempted by surgeons fully familiar with Kasai’s procedure and expert in pediatric endoscopic surgery because transection of the remnant laparoscopically requires extensive laparoscopic skills to ensure satisfactory outcome.

20.7 Pearls/Tips & Tricks 20.7.1 Do’s Milestone 20.3  The portoenterostomy is performed

the enterostomy and liver parenchyma around the margins of the transected portal plate. The posterior margin is performed first, and sutures should be shallow enough to prevent injury to any remnant ductules that may be present, especially at the 2 and 10 o’clock positions, where the original left and right micro bile duct should be (Milestone 20.3).

20.5 Postoperative Care Broad-spectrum antibiotics (usually a cephalosporin and an aminoglycoside) are administered intravenously, commencing at the start of surgery and continued postoperatively until CRP is 180  min). Even though most secondary thrombocytosis cases do not require specific treatment, high-risk post-operative patients with venous thrombosis (e.g. thrombophilia, cancer) may be treated with antiplatelet therapy.

22.9 Postoperative Complications

Milestone 22.3  Clipping of the splenic artery

Surgical complications include bleeding, pancreatitis, subphrenic abscess, thrombosis as well as complications due to unrecognized iatrogenic injuries of the stomach, colon and diaphragm. Medical complications are principally infectious with overwhelming post-splenectomy infection (OPSI) being the most serious, most common in children 3 cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (>500 mL/h on serial ultrasound examinations). In an emergency situation one should certainly always consider the personal experience. If there is any doubt, the classic splenectomy is certainly the safer option. In the hands of an experienced surgeon elective cases of splenectomy in children should nowadays certainly be performed laparoscopically, as the overview in the upper abdomen is usually better and the operative trauma compared to the open splenectomy is significantly reduced [6]. In our clinic, laparoscopic splenectomy is performed as standard via a single incision access via the umbilicus. If intraoperative necessary we place an additional trocar for holding purposes. The procedure is more demanding than a standard laparoscopy. But in our experience it is just as safe and offers the advantage of better cosmetics. In case of any emergency, a classic, open splenectomy is always possible without the need of repositioning.

23.2 Preoperative Workup and Considerations The spleen is the dominant site for the production of IgM antibodies required for opsonizing encapsulated pathogens.

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Thus, whenever elective splenectomy is considered, patients should undergo appropriately timed preoperative immunization against Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), and Haemophilus influenzae type b. In a recently published contemporary national cohort study (inclusion criterion was splenectomy at age 18 years or prior) the prevalence of postsplenectomy sepsis was 7% (1.8 events per 100 person-years). Although most presented during the first year after splenectomy, many (62%) sepsis events occurred later, suggesting that postsplenectomy immunologic dysfunction persists beyond 1 year. The immunologic consequences of asplenia must continue to be acknowledged, as postsplenectomy sepsis remains a serious concern [7]. Therefore, vaccination recommendations for asplenic patients should always be adapted according to current studies and published literature. For orientation it is recommended that the vaccination should be administered 2 weeks before the elective splenectomy. Without prior vaccination, a vaccination interval of 1–2 weeks after splenectomy is recommended [8, 9]. The further preoperative procedure is usually patient-­ specific based on the underlying disease and should always be determined by the treating pediatric surgeon with the treating hematologist or oncologist and infectologist. Children with hemolytic disorders require gallbladder ultrasonography to evaluate for gallstones and possible simultaneous cholecystectomy. Otherwise, coagulation should be checked preoperatively, and packed red blood cells should be crossed because, under certain circumstances, significant bleeding may occur intraoperatively. Since it can make the surgical procedure easier, the colon should be decompressed with either an enema or a laxative on the day before surgery, which often aids in visualization during the OR.

23.3 Anesthetic Considerations On the OR day the patient should be kept NPO per standard protocol. SIPES Splenectomy is typically performed under general endotracheal anesthesia. As splenectomy requires a preparation and ligation of large vessels, resulting in a corresponding risk of bleeding, anesthesia should be performed by an experienced pediatric anesthesiologist. Severe intraoperative bleeding is rare, but having blood available is advisable due to the complex nature of the procedure. At least two peripheral intravenous catheters should be available. In addition, many anesthetists favor intraoperative arterial blood pressure measurement for safe, invasive blood pressure measurement. Hypothermia should be avoided. A nasogastric tube can be of an advantage when there is an important intra-­ abdominal extension of the spleen or when the upper bowel is distended.

J. Goedeke and O. J. Muensterer

A urinary catheter is surgically not required per se once the bladder was emptied preoperatively. However, many anesthesiologists prefer a transurethral bladder catheter for intraoperative circulatory monitoring. A perioperative antibiotic prophylaxis can be done according to general recommendations.

23.4 Operative Technique 23.4.1 Equipment Single Site Access Platform • • • • • • •

5 mm 30° laparoscope 5 mm Maryland dissector 5 mm atraumatic grasper 5 mm laparoscopic sealer/divider 5 mm Metzenbaum scissors 5 mm flexible retractor 10 mm endobag (for small spleens), 15 mm endobag (for large spleens) • 5 mm or 10 mm endoscopic stapler (if required) • 5 mm or 10 mm endoscopic clips (if required)

23.4.2 Positioning The patient is placed in a semilateral position with a 45° tilt of the left side. The table is flexed 20–30° and elevated in a 30° anti-Trendelenburg position. Instead of flexing one could also use a small roll under the left flank to increase the distance between the left iliac crest and the 12th rib. Both arms are extended sideways (Fig. 23.1) or fixed in an overhead position. The patient should be secured by tape to the bed to allow for safe positioning and rotating to both sides during the procedure if necessary. Older children can also be positioned and stored on a vacuum mattress. Surgeon and assistant stand at the right foot of the patient at the end of the bed, the monitor is at the left head end of the bed in-line with the spleen and the surgeon. The scrub nurse is positioned on the right side of the surgeon. The abdomen is prepped and draped from the nipples to the symphysis.

23.4.3 Trocar Placement The single site access platform is placed with the table rotated to the patient’s left to approach a supine position (trocar placement position). The umbilical port site is injected with local anesthesia (for instance 0.25% bupivacaine) at the beginning. The umbilical skin incision is made lengthwise

23  Single Incision Pediatric Endosurgical (SIPES) Splenectomy Fig. 23.1  Positioning of patient, surgeons and monitors

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Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

Legend

SIPES trocar Accessory trocar (if necessary)

away from the operative field, leaving the spleen “hanging” in the left upper quadrant. The spleen is usually positioned anterior to the costodiaphragmatic recess, lateral to the greater curvature of the stomach, adjacent to the tail of the pancreas, anterior to the left kidney, and superior or posterior to the splenic flexure of the colon. Under Vision, if necessary during the procedure, an additional 3 or 5 mm trocar is placed in the left upper abdominal. This would allow the introduction of an additional retractor system. Instead of a regular laparoscopic retractor we sometimes use a 2 mm percutaneous grasper as a retractor.

23.4.4 Operative Milestones Fig. 23.2  Positioning of the trocars

(about 3 cm). A small umbilical fascial defect is usually present, allowing introduction of an Overholt clamp that can guide the fascial incision, which should be about 5  cm. In smaller children it is important to avoid injury to the umbilical vessels, as they still might bleed. After introducing the single site access platform three 5 mm trocars and one 10 mm trocar are inserted via this device (Fig. 23.2). The capnoperitoneum is insufflated using a pressure of 12  mmHg and a flow of 10 l/min. During the procedure, the insufflation pressure can be increased temporarily to provide more sufficient working space. The table is then rotated to the right to achieve a lateral left position (OR position). This helps the viscera to fall

The right-handed surgeon primarily holds a blunt grasper with the left hand and a laparoscopic sealer/divider in the right hand. The first assistant uses primarily a blunt grasper or flexible retractor to elevate the spleen and provide traction on the various ligaments together with the surgeon with the left hand and the camera with his right hand. As the first step in most cases omental attachments to the caudal aspect of the spleen are divided using the sealer device. The surgeon should also evaluate for already visible accessory spleens which could already be removed (Milestone 23.1). After that, it is recommended to divide ligamentous attachments of the spleen. The gastrosplenic ligament at the lower pole of the spleen is usually the ligament to start with. They are divided with the sealer device and additional downward retraction of the colon all the way up to the splenic hilum. This allows the colon to fall away.

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Milestone 23.1 Omental attachments to the caudal aspect of the spleen are divided using the sealer device. The surgeon should also evaluate for already visible accessory spleens which could already be removed (Video 23.1 Splenectomy). (▸ https://doi.org/10.1007/000-2vh)

Milestone 23.2  Exposure of the gastrosplenic ligament, which contains the short gastric vessels, and vessels division and sealing from inferior to superior with the sealer device

After that the assistant retracts the stomach to the right to expose the gastrosplenic ligament, which contains the short gastric vessels, and these vessels are also divided from inferior to superior with the sealer device (Milestone 23.2). The lesser sac should be inspected for the further presence of accessory spleens. At the uppermost portion of the splenogastric ligament the spleen and stomach are very close and the sealer must be placed very close to the spleen in order to avoid gastric injury. At this point the assistant may elevate the upper pole and the diaphragmatic attachments (spleno-

phrenic ligament) may be divided. Take care to avoid injury to the diaphragm. Now the hilum preparation begins. At this point one must decide whether to divide the hilum with individual vessel division (clips, endoscopic sealer, tie) or with a stapling device. For individual vessel division in some cases it might be helpful to keep the splenorenal ligament, which extends from the left kidney to the hilum of the spleen, and the lateral splenic attachments intact to allow the spleen to “hang.” The splenic artery arises from the celiac trunk and travels along the superior edge of the pancreas, where it branches to form the short gastric, left gastroepiploic, and terminal splenic branches. The splenic vein is usually lying caudal from the artery. It forms in the splenorenal ligament and runs inferior to the artery and posterior to the pancreas. It joins the superior mesenteric vein behind the head of the pancreas to form the portal vein. The vessels are prepared close to the hilum and they are gradually ligated and divided with the sealer device near to the hilum (Milestone 23.3). For this purpose, clips or ligatures can also be used. However, the latter are difficult to place in SIPES technique. Thereafter, the remaining splenic adhesions are released. If there is enough distance to the pancreas (at least 1 cm in our experience), the vessels can sometimes be stapled in total using a 10  mm laparoscopic vascular stapler system. For this procedure it is recommended to release the splenorenal ligament and the lateral splenic attachments initially so that the spleen can be fully mobilized prior placing the stapler. Care must be taken to make sure that the tail of the pancreas is not included in the stapler firing. One application

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Milestone 23.3 Vessel preparation close to the hilum and gradually ligation with the sealer device near to the hilum

of the vascular load stapler is usually adequate for ligation and division of the vessels in the hilum. After the spleen is completely free it may be placed high in the left upper quadrant against the anterior abdominal wall and a retrieval bag is placed through the 10 mm Port within single site access platform. It is positioned under the spleen and opened and the spleen is gently dropped into the open bag. The drawstring should be pulled to separate the top of the bag from the ring and the bag will be closed. One could now remove the cap of the single site access platform in order to deliver the neck of the bag through the umbilicus while the wound retractor still remains in place. Quite often the spleen is far a way to huge for direct complete bag removal. Careful morcellation of the spleen using large clamps, sponge sticks or the surgeon’s fingers within the bag may help in this case. The cap of the platform is replaced and completion laparoscopy is performed to ensure adequate hemostasis and to exclude any remaining accessory spleen. Leaving a surgical drain in the operations area is usually not required. If concomitant cholecystectomy is required it could be performed via the same umbilical access after rotating the operating table to the patient’s left to approach a supine position. Otherwise the single site access platform is removed and the fascia at umbilical site is closed with 2–0 polyglactin 910 suture in running suture technique or any other technique. The skin is closed for instance with intracutaneus running suture poliglecaprone 25. Remaining local anesthesia is injected at the umbilicus. Finally we place a vacuum dressing, as this seems to lower the rate of umbilical site infections after laparoscopic surgery [10].

23.5 Postoperative Care Intensive care monitoring is usually not required postoperatively. Postoperative cardiac and pulse oximetry monitoring over 24 h on the floor is usually sufficient and recommended to watch for the development of tachycardia (potential postoperative bleeding). The nasogastric tube and urinary catheter are removed at the end of the procedure. Pain control is achieved by in-­ house standard. A clear liquids diet is instituted upon arrival to the floor with advancement to a regular diet as tolerated. Maintenance intravenous fluids are weaned as the fluid intake advances. Children with sickle-cell-disease are maintained postoperatively on intravenous fluids at a slightly greater then ­maintenance dosage and are carefully monitored to avoid hypoxemia. Most children can be discharged from the hospital after full mobilization. Surgery related postoperative complications are rare and may include umbilical wound healing problem in most cases of complication. Splenectomy increases the risk of thrombosis, especially in the portal vein system [11, 12]. The risk of thrombosis is highest immediately after splenectomy. In childhood, thrombotic complications are less common than in adults. The need for antithrombotic prophylaxis for instance with acetylsalicylic acid is always discussed and should be decided individually according to the latest international guidelines. The increased susceptibility to infection after splenectomy in the young patient emphasizes the need for close

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supervision postoperatively. The length of postoperative antibiotic prophylaxis (usually with penicillin V or amoxicillin) is determined individually according to age. One should always follow the latest international guidelines [13–15]. In order to be prepared for an emergency situation, all our patients receive a medical emergency card “asplenia” (www. aplenia-­net.org).

23.6 Pearls/Tips & Tricks 1. Position the child accurately so that the left side is elevated and use gravity to assist with the dissection. 2. The splenic artery and vein are identified beyond the tail of the pancreas. The splenic vein is usually lying caudal the artery. Vessels can be dissected using many different devices (sealer device, clips, vascular load of staples or even ligatures). 3. It is usually recommended to keep the splenorenal ligament and the lateral attachments intact until completing dissection of the medial aspect of the spleen (hilum, short gastrics). Only in the cases of using stapling devices it is recommended to release the splenorenal ligament and the lateral splenic attachments initially so that the spleen can be fully mobilized prior placing the stapler. 4. The most difficult aspect in short gastric preparation is the uppermost level where the spleen and stomach are very close. Place the sealer very close to the spleen in order to avoid gastric injury. 5. Look for accessory spleens during the procedure in the lesser sac next to the splenic hilum and on the omentum. 6. Be aware of patients with sickle-cell-disease. Children should be maintained postoperatively on intravenous fluids at a slightly greater then maintenance dosage and should be carefully monitored to avoid hypoxemia. 7. Do not hesitate to convert from laparoscopy to laparotomy in unclear situations or any case of emergency.

23.7 Pitfalls & Ways to Avoid 1. The operation is overall not too difficult. However, it can end in a disaster if the surgeon does not know the anatomy. There is a close relationship between spleen and stomach (short gastric vessels), splenic hilum and pancreatic tail, as well as the lower spleen pole and the left colic flexure. One must be aware of this anatomy in order to avoid a stomach injury or pancreatic (tail) injury or fistula.

J. Goedeke and O. J. Muensterer

2. Cases of incidental left nephrectomy instead of splenectomy are described in literature and yellow press. A safe identification of the left kidney and delineation to the spleen is essential before splenectomy. 3. The sealer device may reach high temperatures which easily could cause perforation to adjacent tissue like colon if this tissue is incidentally touched. 4. The jaw of the sealer system may stick to the vessel wall after it has been sealed and transected. A cautious rocking movement will separate the jaws of the sealer from the vessel wall (Video 23.1). If there will be bleeding immediate reclosure and additional sealing on both sides may stop the bleeding in most cases. If bleeding continues, temporary gastric wall compression against the bleeding vessel is another possibility to stop the bleeding. 5. If surgeons use a stapling device for hilum division the tail of the pancreas may be included. Identify the pancreatic tail securely and estimate the distance to the spleen before firing the device. Do not hesitate to change the device to sealer or clips. 6. Take care to avoid injury to the diaphragm. If a hole is made in the diaphragm, a figure-eight suture may be placed and a catheter may be inserted into the chest. While aspirating the pneumothorax the suture can be tied during withdrawal of the catheter.

References 1. Stylianos S, Egorova N, Guice KS, Arons RR, Oldham KT. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg. 2006;202(2):247–51. 2. Stylianos S.  Outcomes from pediatric solid organ injury: role of standardized care guidelines. Curr Opin Pediatr. 2005;17(3):402–6. 3. Polites SF, Zielinski MD, Zarroug AE, Wagie AE, Stylianos S, Habermann EB. Benchmarks for splenectomy in pediatric trauma: how are we doing? J Pediatr Surg. 2015;50(2):339–42. 4. Ermolov AS, Tlibekova MA, Yartsev PA, Guliaev AA, Rogal MM, Samsonov VT, Levitsky VD, Chernysh OA.  Laparoscopic splenectomy in patients with spleen injuries. Surg Laparosc Endosc Percutan Tech. 2015;25(6):483–6. 5. Huang GS, Chance EA, Hileman BM, Emerick ES, Gianetti EA.  Laparoscopic splenectomy in hemodynamically stable blunt trauma. JSLS. 2017;21(2):e2017.00013. 6. Feng S, Qiu Y, Li X, Yang H, Wang C, Yang J, Liu W, Wang A, Yao X, Lai XH.  Laparoscopic versus open splenectomy in children: a systematic review and meta-analysis. Pediatr Surg Int. 2016;32(3):253–9. 7. Madenci AL, Armstrong LB, Kwon NK, Jiang W, Wolf LL, Koehlmoos TP, Ricca RL, Weldon CB, Haider AH, Weil BR. Incidence and risk factors for sepsis after childhood splenectomy. J Pediatr Surg. 2018 Jun 25.

23  Single Incision Pediatric Endosurgical (SIPES) Splenectomy 8. Shatz DV, Schinsky MF, Pais LB, Romero-Steiner S, Kirton OC, Carlone GM. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma. 1998;44:760–5. 9. Shatz DV. Vaccination considerations in the asplenic patient. Expert Rev Vaccines. 2005;4:27–34. 10. Seifarth F, Kundu N, Guerron A, Garland M, Gaffley M, Worley S, Knight C. Umbilical negative pressure dressing for transumbilical appendectomy in children. JSLS. 2016; 20(4). 11. Pietrabissa A, Moretto C, Antonelli G, Morelli L, Marciano E, Mosca F.  Thrombosis in the portal venous system after elective laparoscopic splenectomy. Surg Endosc. 2004;18:1140–3. 12. Stamou KM, Toutouzas KG, Kekis PB, et  al. Prospective study of the incidence and risk factors of postsplenectomy throm-

129 bosis of the portal, mesenteric, and splenic veins. Arch Surg. 2006;141:663–9. 13. Di Sabatino A, Carsetti R, Corazza GR.  Post-splenectomy and hyposplenic states. Lancet. 2011;378:86–97. 14. Davies JM, Lewis MP, Wimperis J, et  al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a working party of the Haemato-Oncology task force. Br J Haematol. 2011;155:308–17. 15. Salvadori M, Price V, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Preventing and treating infections in children with asplenia or hyposplenia. Paediatr Child Health. 2014;19(5):271–4.

Laparoscopic Partial Splenectomy

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Peter Zimmermann, Illya Martynov, and Martin Lacher

24.1 I ndications for Laparoscopic Partial Splenectomy

24.2 Preoperative Workup and Considerations

The spleen is an important organ of the immune system. Total splenectomy carries the risk of overwhelming post-­ splenectomy infection (OPSI) which can occur in up to 4.4% of patients with a mortality rate of 50–80% [1]. Partial splenectomy can prevent post-splenectomy infections by preserving the immunologic function of the spleen [2]. The segmental vascular supply of the spleen with the splenic artery dividing in the hilum in two (86%) or three (12%) lobar arteries makes partial splenectomy feasible. However, approximately two percent of the spleens have multiple lobar arteries or a unique non-divided artery making partial splenectomy difficult or impossible [3]. Today, the laparoscopic approach has become the gold standard [4]. Laparoscopic partial splenectomy (LPS) combines the benefits of partial splenectomy and minimally invasive surgery [2]. Initial control of the vascular pedicle with ligation of the terminal splenic vessels leads to an ischemic demarcation of the parenchyma and allows its transection with minimal blood loss. Indications for LPS include splenic cystic lesions (congenital, parasitic, traumatic), hematological diseases with splenomegaly like hereditary spherocytosis, thalassemia and sickle cell disease, splenic rupture or abscess [2].

Due to the risk of conversion to total splenectomy all children should be vaccinated according to current recommendations for asplenic patients at least 2 weeks before surgery. Further workup is based on the underlying disease.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_24. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. P. Zimmermann (*) · I. Martynov · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]

24.3 Anesthetic Considerations LPS is performed under general endotracheal anesthesia. Routine pulse oximetry is used. In experienced hands central venous lines, arterial lines, and Foley catheters are not routinely required. At least two peripheral intravenous catheters should be available and cross-matched blood accessible in the operating room. A nasogastric tube is routinely placed for gastric decompression. A perioperative antibiotic prophylaxis is administered. There is no need for epidural or spinal anesthesia.

24.4 Operative Technique 24.4.1 Equipment • • • • • • • • • • • •

10–12 mm camera port 5 mm camera (30–45°) Three 5 mm working ports Two atraumatic graspers Kelly/Maryland dissector 5 mm metal probe Metzenbaum scissors Monopolar hook cautery Suction device/Irrigator Endoscopic Clips Sealing device 12 mm Specimen retrieval bag

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24.4.2 Positioning The patient is placed in supine position with a 45° tilt of the left side. The table is flexed 20–30° and elevated in a 30° anti-Trendelenburg position. Instead of flexing the table a small roll may be placed under the left flank. The patient should be secured to the table by tape or a belt to allow for safe positioning and rotating to both sides during the procedure if necessary. Older children can also be positioned and stored on a vacuum mattress. The surgeon and the assistant stand on the right of the operating table. The monitor is in line with the spleen and the surgeon at the left proximal end of the table. The scrub nurse is positioned on the left side or the distal end of the table (Fig. 24.1). The abdomen is prepped and draped from the nipples to the symphysis.

24.4.3 Trocar Placement A vertical 10–12  mm incision is carried out at the deepest point of the umbilicus for insertion of the camera port. Since the umbilical port site will be widened later for extraction of the splenic specimen, we do not refrain from making a rather large incision. A 10–12 mm camera port is inserted. We prefer ports with a balloon at the tip because this prevents dislocation while maintaining pneumoperitoneum. Ports without a balloon should be secured by a purse-string suture tied to the stopcock in order to achieve an airtight seal and to prevent the trocar from slipping out. A 5 mm camera (30–45°) is inserted and CO2 insufflation started at a pressure of

8–10  mmHg with a CO2 flow of 4–6  L/min. Three 5  mm working ports are inserted in the left lower quadrant, the mid-epigastrium and below the xiphoid.

24.4.4 Operative Milestones Dissection begins by division of the epiploic attachments (gastro colic ligament) to access the lesser sac. The short gastric vessels are divided as needed and the stomach is grabbed sufficiently high on the posterior aspect of the greater curvature for better exposure of the anterior part of the splenic hilum with the vascular pedicle. The number of segmental arteries is identified (Milestone 24.1). If two arteries are present a hemisplenectomy can be performed. In case of three arteries the choice will be to perform either a one third or a two third splenectomy. Depending on the underlying pathology an upper or lower pole resection will be done and branches of the splenic artery to the lower or the upper pole are preserved. The branches of the vascular pedicle are carefully dissected and freed for 1–2 cm in order to get enough and safe length (Milestone 24.2). Any laceration of the spleen should be avoided as bleeding from the parenchyma is much more difficult to control than bleeding from a vessel. The vessels are clipped twice centrally and once peripherally (Milestone 24.3). Alternatively, the distal part onto the spleen is sealed. Locking-clips are recommended as the risk for clip-­dislocation is lower. Once the chosen terminal splenic vessels are divided an ischemic demarcation line between the vascularized and ischemic parts can be seen. Then the spleen is divided with a sealing

Fig. 24.1 Positioning

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

45  Laparoscopic Partial Splenectomy

Milestone 24.1 Exposure of the anterior part of the splenic hilum with the pedicle and identification of the number of segmental arteries. Retraction of the vessels is facilitated with a soft silicone rubber band (“vessel-loop”) (Video 24.1 Partial splenectomy). (▸ https://doi.org/10.1007/000-2vj)

Milestone 24.2  The branches of the vascular pedicle are carefully dissected and freed for 1–2 cm in order to get enough and safe length. Retraction of the vessels with a soft silicone rubber band (“vessel-­ loop”) leads to a smaller diameter of the vessel making the ligation with endoclips easier

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Milestone 24.4  The spleen is divided with a sealing device in the devascularized part close to the demarcation line

ing the phrenosplenic ligaments and the upper lateral attachments to mobilize the upper pole. In case of lower pole partial splenectomy, the posterior and splenorenal ligaments and the lower lateral attachments are divided. The resected part of the spleen is placed into a retrieval bag introduced through the umbilical port. For this step the 5 mm camera is moved to the left lower quadrant port. The umbilical fascia incision is enlarged, and the margins of the bag are extracted through the umbilicus. The spleen is digitally fragmented in the bag and pieces are extracted with graspers or suction. The camera port is inserted again to ensure adequate hemostasis. A drain may be placed for early indication of postoperative bleeding.

24.5 Postoperative Care Intensive care monitoring is not mandatory but postoperative cardiac and pulse oximetry monitoring over 24 h is recommended to detect tachycardia as a possible sign of potential postoperative bleeding. The child can be discharged when comfortable on oral pain medication and tolerating adequate oral intake. Just before discharge an ultrasound is made to asses possible fluid collections.

24.6 Pearls/Tips & Tricks Milestone 24.3  The vessels are clipped with locking-clips as the risk for clip-dislocation is lower

device close to the demarcation line but in the devascularized part (Milestone 24.4). Any remaining bleeding vessels are treated with the sealer or monopolar spray coagulation. For upper pole resection the dissection is pursued by incis-

1. A 5  mm, 30–45° angled camera allows visualization in different angles and insertion into the umbilical port and the port in the left lower quadrant without changing the camera. 2. If a 10/12 mm camera port is placed in the umbilicus a 10 mm camera can also be used to increase the quality of imaging especially in case of severe bleeding.

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3. Tilting the operating table improves the exposure by using gravity retracting the spleen. 4. To avoid gastric injury, the sealer should be placed very close to the spleen during division of the short gastric vessels. 5. Due to the risk of conversion to total splenectomy all children should be vaccinated at least 2 weeks before surgery according to current recommendations for asplenic patients.

24.7 Pitfalls & Ways to Avoid 1. Any laceration of the spleen should be avoided as bleeding from the parenchyma is much more difficult to control than bleeding from a vessel. 2. In case of unclear anatomy, multiple lobar arteries or a unique non-divided artery a partial splenectomy may be impossible, and total splenectomy is the only option.

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3. Be aware that the electrocautery or the sealer device may reach high temperatures and potentially harm adjacent structures like the colon or stomach. 4. The spleen can be digitally fragmented in the bag and pieces are extracted with graspers or suction. Any damage to the bag should be avoided (Video 24.1).

References 1. Mouttalib S, Rice HE, Snyder D, et  al. Evaluation of partial and total splenectomy in children with sickle cell disease using an Internet-based registry. Pediatr Blood Cancer. 2012;59:100–4. 2. Liu G, Fan Y.  Feasibility and safety of laparoscopic partial splenectomy: a systematic review. World J Surg. 2019;43(6):1505–18. https://doi.org/10.1007/s00268-019-04946-8. 3. Liu DL, Xia S, Xu W, Ye Q, Gao Y, Qian J.  Anatomy of vasculature of 850 spleen specimens and its application in partial splenectomy. Surgery. 1996;119(1):27–33. https://doi.org/10.1016/ s0039-6060(96)80209-1. 4. Feng S, Qiu Y, Li X, et  al. Laparoscopic versus open splenectomy in children: a systematic review and meta-analysis. Pediatr Surg Int. 2016;32(3):253–9. https://doi.org/10.1007/s00383-015-3845-2.

Part V Oncology

General Oncologic Endosurgical Procedures

25

Lucas Krauel, Rosalia Carrasco, and Margarita Vancells

25.1 Introduction Minimally invasive surgery (MIS) has become the standard procedure for various types of pediatric surgical procedures such as appendectomy, cholecystectomy, fundoplication, splenectomy, and nephrectomy. Over the past decades, there has been an increase number of reports about feasibility and safety of MIS in pediatric surgical oncology. Unfortunately, no randomized controlled trials or controlled trials that evaluate MIS in the treatment of solid tumors in children have been published [1]. Main limitations for the implementation of MIS in surgical oncology are the limited number of patients, the heterogeneity of tumor types, the wide variety of anatomical locations as well as the different clinical presentation and patient condition having to adapt the surgical techniques to each and one specific patient characteristics and needs. This heterogeneity implies different treatment concepts. In some tumors, microscopical residual disease is an important prognostic factor and wide resection margins are needed, while in others leaving some residual tumor tissue behind is accepted. Due to this particularity no single standard surgical MIS procedure can be adopted. Another widely reported technical limitation is the tumor volume and the small working space of pediatric patients compared with adults that limits surgical exposure [2, 3]. Surgical oncology is an important aspect of a multidisciplinary approach to children with cancer which main goal are to cure and/or increase survival and event free survival Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_25. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. L. Krauel (*) · R. Carrasco · M. Vancells Pediatric Surgery Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain e-mail: [email protected]

rates with the least of complications and sequel. Therefore MIS in surgical oncology should adhere to these oncologic principles and prevent potential complications related to MIS such as tumor spillage, tumor recurrence, inadequate tumor exposure, incomplete resections or difficulties in specimen removal through small incisions. Improvements of surgical instruments, surgical planning, robotic surgery and interventional radiology are progressively overcoming these problems and therefore acceptance of MIS in pediatric oncology is increasing. Oncologic surgery in children may benefit from the advantages of MIS in terms of less pain and faster recovery that might lead to an earlier adjuvant treatment.

25.2 Indications for Oncologic Endosurgical Procedures Major indications can be divided in two anatomical compartments, thorax and abdomen and in relation to the main purpose of the surgery in: Biopsy, tumor resection, surgery of metastases, and supportive treatment including female fertility preservation. Thorax: Most common procedures in the thorax are biopsies, surgery on pulmonary nodules (metastatic and non-metastatic) [4] and lesions of the posterior mediastinum, mainly neurogenic tumors. Thoracoscopy can also be used for complicated pleural effusions and perform mechanical pleurodesis. Abdomen: Main indications in this compartment are tumor biopsies, adrenal tumors, renal and ovarian tumors and surgery for ovarian function preservation [5]. There is an increased tendency to resect Wilms tumors laparoscopically after preoperative chemotherapy in European studies. Tumor size within the ipsilateral vertebral border is associated with feasibility of this approach. The

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same open surgery principles for Wilms tumor and lymph node sampling should apply if MIS is chosen. For malignant ovarian tumors complete resection is mandatory. Some authors always recommend laparotomy to limit the risk of tumor spillage. However, others prefer MIS, cautiously indicated, in small tumors. Laparoscopy has a defined role for oncologic staging. Ovarian function preservation should always be taken in consideration. Various procedures are available. Ovarian cryopreservation implies cortex ovarian sampling through laparoscopy. This can be performed at the time of other procedures that might require general anesthesia.

25.3 Preoperative Workup and Considerations Preoperative workup depends on tumor type, location, procedure and patient condition. All patients should be evaluated by a multidisciplinary tumor board prior to surgery. A thorough imaging workup looking for tumor anatomical relations is mandatory. New 3D virtual reconstructions are emerging as a helpful tool for surgical planning. Blood analysis with red and white count, platelets and coagulation analysis should be carefully monitored prior to surgery especially in patients undergoing chemotherapy. The need for any kind of transfusion should be considered. Previous surgeries and/ or radiation therapy should always have to be taken in consideration before choosing MIS. If an emergency procedure has to be performed prior to having a clear diagnosis, special attention has to be taken in tissue handling and to assure serum banking for future analysis such as tumor markers that might change after tumor removal.

25.4 Anesthetic Considerations All oncologic MIS procedures are typically performed under general anesthesia. General considerations regarding naso- or orogastric tube and Foley catheter apply depending on specific anatomic working area and duration of surgery. At least 2 peripheral intravenous catheters should be available and a central venous catheter for major oncologic procedures. Intraoperative bleeding can occur even in the event of biopsy sampling. Having blood available is advisable. For thoracic surgery, the use of single lung ventilation is generally recommended. This can be challenging in small children. Mechanical ventilation problems can be relevant due to the increased intrathoracic pressure and lung compression.

L. Krauel et al.

25.5 Operative Technique Every case should be discussed in a multidisciplinary tumor board and surgical procedures tailored to the patient specific needs. Thorax: As the most common thoracoscopic procedure in children with cancer is biopsy/excision of pulmonary nodules for confirming metastatic lesions or other lesions such as potential infectious infiltrates in immunocompromised patients, we will focus on this procedure. While superficial lesions are usually easy to identify, deeper lung nodules surrounded by normal parenchyma or milimetric in size are difficult to locate. CT-guided wire localization followed by thoracoscopic wedge resection can overcome this limitation. Abdomen: Specific organ surgery is described elsewhere. MIS principles for each targeted organ apply to surgical oncology taken in consideration the preservation of the standards and goals of oncological principles. A case of ovarian function preservation is presented as the demand is increasing and the procedure can be standardized. Most endosurgical oncologic cases can be accomplished with the following equipment:

25.5.1 Equipment • • • • • • • • • • • • •

5 mm optical trocar (0°/30°) 5–12 mm working ports Endoscopic specimen retrieval bag Endosurgical stapler Endosurgical suction Atraumatic grasper Maryland dissector Metzenbaum scissors Hook monopolar cautery Bipolar cautery and sealing device Surgical clips Suture ligatures 18G 120mm spiral harpoon (pulmonary nodules)

25.5.2 Positioning Thorax: The patient is placed in lateral decubitus position with the affected side elevated (Fig. 25.1). If a wire has been placed for lesion location, special care has to be taken to prevent

25  General Oncologic Endosurgical Procedures Fig. 25.1  Positioning of patient, surgeons and monitor

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Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

dislocation. A silicone or towel roll is placed under the thorax in order to open the working space and facilitate port introduction. Careful padding between the legs and pressure areas is applied. The arms are positioned in a 90° position ensuring that there is no brachial plexus compression on the lower arm. The patient is supported to allow tilting the table if required for better visualization. The surgeon and assistant are on the same side facing the patient across from the lesion with the monitor across from them usually at midchest level. The scrub nurse is standing across the table. Abdomen: The patient is placed supine in decubitus position with arms tucked to side (Fig. 25.3). The operator stands on either side depending on the ovary to sample and the first assistant on the contralateral side. The monitor is placed toward the patient feet to have the ovary in line between the camera and the monitor.

Legend Working trocar Endoscope trocar Accessory trocars

Fig. 25.2  Trocars in place

25.5.3 Trocar Placement

25.5.4 Operative Milestones

Thorax: A 0° or 30° scope is introduced via a 5 mm trocar in the midaxillary line on the fifth or sixth intercostal space or away from the wire to allow visualization. Low CO2 pressures (4–6 mmHg) are used to make the lungs collapse and improve visualization. Two additional 5  mm trocar are placed under direct vision on either side and away from the camera to allow free working movements. The working trocar that allows better stapler positioning will be replaced by a 12 mm port (Fig. 25.2). Abdomen: A 5 mm 0° or 30° scope is introduced through the umbilicus. Two other 5 mm working trocars are placed in the lower abdomen bilaterally (Figs. 25.3 and 25.4).

Thorax: The operation begins with a general inspection of the  whole thorax looking for possible other lesions. Adhesions can be freed using the hook cautery. Once the lesion is identified, it is gently grasped. If the lesion has been ­ previously wired, it usually remains elevated (Milestone 25.1). Depending on the location of the lesion, the trocar with the best working angle will be used for introducing the endosurgical stapler. The lesion will be then mobilized with the grasper to allow the correct placement of the stapler making sure the lesion remains above the stapler at all times (Milestone 25.2).

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Fig. 25.3  Positioning of patient, surgeons and monitors

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse Instrument table

Legend Working trocar Endoscope trocar Accessory trocar

Fig. 25.4  Trocars in place

Milestone 25.2  Placement of the stapler making sure the lesion remains above the stapler at all times (Video 25.2 Ovarian function preservation). (▸ https://doi.org/10.1007/000-2vk)

Milestone 25.1  Identification of the lesion (Video 25.1 VATS pulmonary nodules). (▸ https://doi.org/10.1007/000-2vm)

After reassuring that the lesion is not trapped within the stapler, the device is fired. Sometimes another load is necessary. The specimen is then removed with a retrieval bag to avoid spillage; it is thoroughly inspected and sent to the pathologist for histologic analysis (Milestone 25.3). CO2 pressure is stopped and drained. The thorax is then filled with saline and the lung expanded carefully looking for a possible air leak (Milestone 25.4). After aspiration of the remaining saline, a chest tube is placed under direct vision. Abdomen: A thorough inspection of the abdominal cavity is performed. The selected ovary is then gently mobilized for better exposure (Milestone 25.5). An approximately 1 square cm of the cortex of the ovary is cut with scissors (Milestone

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Milestone 25.3  The specimen is then removed with a retrieval bag Milestone 25.5  Selection and gentle mobilization of the ovary

Milestone 25.4  Infusion of saline into the thorax to identify a possible air leak while the lung is expanding

Milestone 25.6  An approximately 1 cm2 of the cortex of the ovary is cut with scissors. (▸ https://doi.org/10.1007/978-­3-­030-­58043-­8_25)

25.6). Nevertheless, the amount of tissue will depend on the patients age and ovary size. The specimen is then retrieved and rapidly processed for cryopreservation by the tissue bank. The remaining ovarian tissue usually bleeds and is coagulated with bipolar cautery (Milestone 25.7).

25.6 Postoperative Care Thorax: If there is no air leak the next morning, chest tube is clamped, a chest X-ray performed after 2  h and the chest tube removed if no pneumothorax is seen. The patient is then discharged. A p­ ossible postoperative complication, although

Milestone 25.7  Coagulation of the remaining ovarian tissue, which usually bleeds

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uncommon when using a stapler, is air leak. In this case, chest tube is left until the air leak resolves. Abdomen: This is a very straightforward procedure. An immediate return to normal activities without restrictions is allowed depending on the patient clinical condition. The procedure may be performed in an outpatient setting.

25.7 Pearls/Tips & Tricks Thorax 1. When using a CT-guided spiral wire, the lung remains very well attached to it and acting like a grasper and the procedure can be attempted with just two trocars. 2. If a short segment of lung tissue is not included in the stapler line, an endoloop can be placed instead of using another load. 3. Always check the specimen after retrieval to assure the lesion is contained within the tissue and resection margins are free. Abdomen 1. A 3 mm trocar for the scope and one as a working trocar can be used as well.

25.8 Pitfalls & Ways to Avoid Thorax 1. There are many other techniques described to mark pulmonary lesions that are difficult to locate. The advantage of spiral wires is that they hold very well onto the lung

L. Krauel et al.

and chances for dislocation are low. Special care has to be taken when mobilizing or transferring the patient from the CT. 2. The wire should be placed next to the lesion not through it to avoid potential spillage. 3. If the wire is dislodged use lung bleeding point as your anatomical reference. 4. Make sure CO2 pressure is off and trocars open before expanding the lung. 5. Chances of air leak are low with endo staplers but air leak might still occur. If the leak is minimal it will resolve with the chest tube left in place and it is better not to attempt re-­suturing the lung. Abdomen 1. A cryofertility program has to be coordinated with a tissue banking facility (Videos 25.1 and 25.2).

References 1. van Dalen EC, de Lijster MS, Leijssen LGJ, Michiels EMC, Kremer LCM, Caron HN, Aronson DC. Minimally invasive surgery versus open surgery for the treatment of solid abdominal and thoracic neoplasms in children. Cochrane Datab Syst Rev 2015, Issue 1. CD008403. https://doi.org/10.1002/14651858.CD008403.pub3. 2. Fuchs J, Schafbuch L, Ebinger M, Schäfer JF, Seitz G, Warmann SW. Minimally invasive surgery for pediatric tumors – current state of the art. Front Pediatr. 2014;2:48. 3. Boo YJ, Goedecke J, Muensterer OJ. Pediatric oncologic endosurgery. Int J Surgery Oncol. 2017;2(7):e30. 4. Murrell Z, Dickie B, Dasgupta R. Lung nodules in pediatric oncology patients: a prediction rule for when to biopsy. J Pediatr Surg. 2011;46(5):833–7. 5. Donnez J, Dolmans M-M.  Ovarian cortex transplantation: 60 reported live births brings the success and worldwide expansion of the technique towards routine clinical practice. J Assist Reprod Genet. 2015;32(8):1167–70.

Laparoscopic Adrenalectomy

26

Christoph Zoeller, Benno Ure, Joachim F. Kuebler, and Jens Dingemann

26.1 Indications for Laparoscopic Adrenalectomy Laparoscopic adrenal surgery for adrenal pathologies represents the standard approach for many pediatric surgical centers today [1]. Typical indications are resection of neurogenic tumors, adenomas and pheochromocytomas. For neurogenic malignancies, it has been shown that there is no difference between open and laparoscopic surgery in 30-day mortality, readmissions, surgical margin status, and 1- and 3-year survival in selected cases [2]. Principally, the trans-peritoneal or the retro-peritoneal approach are possible. For adults, it has been shown that the retro-peritoneal approach is superior regarding various aspects [3]. For children, no reliable data on the role of the different approaches are available. Commonly, pediatric surgeons prefer the trans-peritoneal technique, which will be subject of this chapter.

26.2 Preoperative Workup and Considerations Patients with adrenal mass are usually transferred to the pediatric surgeon by a pediatric oncologist or endocrinologist. Most of them will have undergone ultrasound, scintigraphy, MRI or CT and disease-specific laboratory work-up. The decision for or against a laparoscopic approach for adrenalectomy is made by the interdisciplinary tumor-board for each patient on an individual basis in our institution, depending on tumor-size, as well as stage and localization. For left Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_26. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. C. Zoeller · B. Ure · J. F. Kuebler · J. Dingemann (*) Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany e-mail: [email protected]

adrenalectomy in small patients, we prefer the administration of a saline enema the morning of the operation to clean out the sigmoid- and descending colon for better exposure of the adrenal gland. Preoperative preparation of patients with pheochromocytomas requires alpha receptor blockage. For right adrenalectomy, bowel preparation is not necessary.

26.3 Anesthetic Considerations Laparoscopic adrenalectomy is performed under general anesthesia and endotracheal intubation. Caution has to be taken regarding the anesthesia of patients with catecholamine producing tumors (neuroblastoma), as catecholamines may interact with anesthetic agents. Establishment of the capnoperitoneum, ligation of the adrenal vein and dissection/ manipulation of the adrenal mass are the operative phases that pose the highest risk for catecholamine-release. An arterial catheter is mandatory in cases where hemodynamic instability due to flush of catecholamines during resection is expected. A urinary catheter and antibiotic prophylaxis are not deemed necessary.

26.4 Operative Technique 26.4.1 Equipment • • • • • • • • • • •

5 mm or 3.5 mm Instruments and Trocars 5 mm or 10 mm 30° telescope Atraumatic graspers Monopolar dissecting hook (grounding pad) Curved dissecting scissors Hooked scissors Blunt palpation probe 5 mm clip applier 5 mm advanced bipolar sealer/divider 5 mm liver retractor (for right adrenalectomy) 10 mm tissue retrieval bag

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26.4.2 Positioning We prefer a semi-lateral position (45°) with the lesion side up. The patients are routinely placed on a vacuum mattress to secure them to the bed. The ipsilateral arm can be placed overhead in infants and newborns or hung in a sling in older children. During the procedure, it may be helpful to tilt the table to a full lateral position and raised head. The surgeon’s position is on the anterior side of the patient, the first assistant’s on the posterior side for introduction of the ports. Two monitors are placed at the anterior and posterior side of the patient. After introduction of the ports, both surgeons will stand at the anterior side of the patient and work in the same direction. If needed, a second assistant is placed on the posterior side of the patient to assist with a retractor or palpation probe (Fig. 26.1).

26.4.3 Trocar Placement For introduction of the first (optical) trocar, an open approach is preferred. The skin is incised according to the diameter of the trocar and the fascia is opened using monopolar diathermy dissection. When using a 10  mm optical trocar, a purse string suture is used to secure it in “fascial sleeve technique” [4] and for closure of the fascia at this site at the end of the operation. The introduction of all further ports is performed under direct visualization (Fig. 26.2). Fig. 26.1  Positioning of patient, surgeons and monitors

The port for the telescope is usually placed in a subumbilical or transumbilical position. The location of the other ports follow the lateral costal margin. The working ports are placed with sufficient distance left and right to the camera port in a triangular arrangement pointing at the operative field. For right adrenalectomy, one more trocar is needed anteriorly along the costal margin for the liver retractor.

26.4.4 Operative Milestones After introducing the optical trocar at the umblicus, the capnoperitoneum is established at a maximum pressure of 8 mmHg and a maximum flow of not more than 5 l/min. Working trocars are inserted as described above. For right adrenalectomy, the right lobe of the liver is retracted superiorly and the right triangular ligament is divided to improve exposure. The peritoneum is incised at the upper pole of the right kidney to open Gerota’s fascia and the ventral surface of the adrenal gland is identified (Milestone 26.1). Further dissection with monopolar diathermy or an advanced bipolar sealing device follows the surface of the adrenal gland and the tumor respectively. The adrenal vein is identified at the junction with the inferior vena cava, dissected and clipped with clips or sealed and divided with the sealer (Milestone 26.2). The adrenal arteries and surrounding tissue are then dissected/sealed and divided at the superior and medial aspect first and

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

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Legend

Working trocar Endoscope trocar Accessory trocar

Milestone 26.3  Dissection of the adrenal gland/tumor

Fig. 26.2  Trocar positioning for left laparoscopic adrenalectomy

the abovementioned way. Clipping or sealing and division of the adrenal vein at the junction with the left renal vein are not different from right adrenalectomy. Once the gland has been completely dissected, it can be removed using a retrieval bag or—in small glands—directly through the 10 mm trocar. The working trocars are removed under vision, 5  mm and 3.5  mm incisions are closed with resorbable sutures in layers, at the umbilical incision, the purse string suture is tied and the skin is closed with intra-­ cutaneous stiches or with a vacuum dressing [5] in transumbilical incisions.

26.5 Postoperative Care Milestone 26.1  Exposure of the adrenal gland at the upper pole of the  kidney (Video 26.1 Laparoscopic Adrenalectomy) (▸ https://doi.org/10.1007/000-2vn)

Immediate mobilization and advancement of diet may be started. Intensive care management may be required for catecholamine producing tumors. Hemodynamic observation is also mandatory in patients undergoing bilateral resection. If needed, hormone substitution shall be planned preoperatively in these special patients, together with the pediatric endocrinologist.

26.6 Pearls/Tips & Tricks

Milestone 26.2  Clipping and division of the adrenal vein

finally postero-laterally using monopolar cautery and/or the sealer (Milestone 26.3). For left adrenalectomy, the upper pole of the left kidney is exposed by dividing the lateral pancreatic and splenic peritoneal attachments and those of the descending colon and local opening of Gerota’s fascia. After identification of the lower extent of the adrenal gland, dissection is started from here in

1. Dissect and ligate the adrenal vein first and avoid excessive manipulation of the adrenal gland in pheochromocytomas. This will reduce the risk of catecholamine flush (Video 26.1). 2. Use an advanced bipolar sealer for dissection of the gland to avoid bleeding from the multiple adrenal arteries (Video 26.1). 3. To avoid diffuse bleeding from the resection site, a pre-­ rolled hemostatic sponge may be applied at the end of the operation. It may be difficult to introduce through the 10 mm optical trocar. Therefore, insert a grasper in a retrograde fashion into the 10  mm trocar and “pull it inside”.

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References 1. Fascetti-Leon F, Scotton G, Pio L, Beltrà R, Caione P, Esposito C, Mattioli G, Saxena AK, Sarnacki S, Gamba P. Minimally invasive resection of adrenal masses in infants and children: results of a European multi-center survey. Surg Endosc. 2017;31(11):4505–12. https://doi.org/10.1007/s00464-­017-­5506-­0. Epub 2017 May 26 2. Ezekian B, Englum BR, Gulack BC, Rialon KL, Kim J, Talbot LJ, Adibe OO, Routh JC, Tracy ET, Rice HE.  Comparing oncologic outcomes after minimally invasive and open surgery for pediatric neuroblastoma and Wilms tumor. Pediatr Blood Cancer. 2018;65(1) https://doi.org/10.1002/pbc.26755. Epub 2017 Aug 9

C. Zoeller et al. 3. Barczyński M, Konturek A, Nowak W.  Randomized clinical trial of posterior retroperitoneoscopic adrenalectomy versus lateral transperitoneal laparoscopic adrenalectomy with a 5-year follow­up. Ann Surg. 2014;260(5):740–7. ; discussion 747–8. https://doi. org/10.1097/SLA.0000000000000982. 4. Metzelder ML, Ure BM. Fascial fixation of sleeved trocar prevents trocar dislocation and allows adjustment in pediatric laparoscopy. J Laparoendosc Adv Surg Tech A. 2007;17(2):276. 5. Visser R, Milbrandt K, Lum Min S, Wiseman N, Hancock BJ, Morris M, Keijzer R.  Applying vacuum to accomplish reduced wound infections in laparoscopic pediatric surgery. J Pediatr Surg. 2017;52(5):849–52. https://doi.org/10.1016/j.jpedsurg.2017.01.035. Epub 2017 Jan 30

Ovarian Procedures: Laparoscopic Ovarian Preserving Cystectomy and Laparoscopic Detorsion

27

Thomas M. Benkoe and Martin L. Metzelder

27.1 Indications for Laparoscopic Approach to Ovarian Torsion and Benign Ovarian Masses Most ovarian masses in children and adolescents are benign [1]. Preservation of ovarian tissue is key to facilitate future hormonal health and fertility. However, high oophorectomy rates in benign diseases are still reported in pediatric surgical literature despite the endorsement of ovarian sparing techniques [2]. Adolescent girls who undergo surgery for ovarian lesions are at risk to develop processes in the contralateral ovary including neoplasm and/or torsion [3]. This places the patients at risk for possible infertility, especially after initial tubo-oophorectomy when an oophorectomy is needed at the contralateral side. The estimated overall risk to encounter a malignant ovarian mass is 10% [4]. Due to this circumstance a thorough preoperative risk stratification to identify those being at highest risk for malignancy is mandatory, as this affects the surgical approach, and the type of resection. The basic principle of ovarian sparing techniques (ovarian cystectomy, partial oophorectomy with complete mass resection, detorsion, fenestration, or unroofing of ovarian cysts) is to resect abnormal tissue while preserving normal ovarian tissue [1, 2]. Irrespective of the surgical approach, the most important factor for recurrence in a cystic or benign lesion is an incomplete resection. Although the reported rate of intra-

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_27. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. T. M. Benkoe (*) · M. L. Metzelder Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria e-mail: [email protected]; martin.metzelder@ meduniwien.ac.at

operative cyst fluid spillage is much higher in the group of laparoscopic procedures compared to conventional operations, the rate of recurrence and need for repeat cystectomy is not different [5].

27.2 Preoperative Workup and Considerations The initial symptoms are often non-specific and include abdominal pain, a palpable mass, abdominal distension, or precocious puberty and are not an accurate indicator of malignancy. Preoperative tumor markers need to include alpha-fetoprotein (AFP), ß-human chorionic gonadotropin (ßHCG), lactate dehydrogenase (LDH), cancer antigen 125 (CA-125) and the sex hormones estradiol and testosterone [7]. Ultrasound is the standard imaging modality for initial evaluation. Indicators for malignancy are the presence of solid components, enhanced blood flow in a thickened septum and the size of the ovarian mass >8 cm [1, 4]. In cases of suspected malignancy further imaging with magnetic resonance imaging (MRI) or computed tomography (CT) scans are needed, but should not result in delayed treatment, particularly when torsion is suspected.

27.3 Anaesthetic Considerations Laparoscopic procedures on the ovaries are generally performed under general anaesthesia and endotracheal intubation. To ease the procedure a transurethral catheter should be inserted. Intraoperative bleeding is usually negligible, and therefore no central venous line is needed. Preoperative bowel preparation is not mandatory. Perioperative antibiotic treatment is not required.

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Fig. 27.1  Positioning of patient, surgeons, trocars, and monitors

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

27.4 Operative Technique 27.4.1 Equipment • • • • • • •

3 or 5 mm instruments and trocars 5 mm or 10 mm 30° laparoscope 3 mm or 5 mm Maryland dissector 3 mm or 5 mm atraumatic grasper 5 mm Metzenbaum scissors 3 mm or 5 mm hook monopolar cautery (grounding pad) 5 mm sealing device

27.4.2 Positioning The patient is placed in supine position with the arms tucked to the side. The surgeons and the first assistants position in older children is contralateral to the affected side of the ovary, while in infants and smaller children the assistant is on the ipsilateral side. Irrespective of the size of the patient the surgeon and the assistant always face a monitor in front (Fig. 27.1). Fig. 27.2  Trocar placement

27  Ovarian Procedures: Laparoscopic Ovarian Preserving Cystectomy and Laparoscopic Detorsion

27.4.3 Trocar Placement The first trocar (either 5 mm or 10 mm) is placed at the umbilicus and a capnoperitoneum is established using a pressure of 6  mmHg in infants and 10  mmHg in older children. In general two 3–5 mm working trocars are placed under direct vision in the left and right lower quadrant of the abdomen (Fig. 27.2).

27.4.4 Operative Milestones The procedure starts with the exploration of the pelvic region. With regard to the preoperative imaging the affected ovary is investigated to confirm the suitability for a tissue sparing cystectomy. At this timepoint it is crucial to identify normal appearing ovarian tissue (Milestone 27.1). Irrespective of preoperative anticipated benign disease it is mandatory to add a collection of ascites, the exploration of the peritoneum, mesentery, omentum majus and the diaphragm according to the current staging recommendations for ovarian tumors [6]. A biopsy of a normal appearing contralateral ovary is not required. It is important to keep intraoperative malignancy criteria in mind prior to any attempt of tissue sparing removal of an ovarian mass. Even if pre- and intra-operative evaluation does not reveal any signs of malignancy we advise to place an endobag around the affected ovary to control cyst content spillage in cases of inadverted rupture (Milestone 27.2). Dissection of the ovary starts with a superficial incision of the capsule using a monopolar hook (Milestone 27.3), followed by meticulous circular mobilization of the cyst (Milestone 27.4). To this regard, the mobilization is facilitated using scissors or an endoscopic sealing device to control bleeding. After the cyst is completely resected (Milestone 27.5), the endobag is closed over the specimen and removed via the umbilical trocar incision.

Milestone 27.1 Identification of the normal appearing ovarian tissue and the benign ovarian mass; preoperative MRI and corresponding intraoperative lesion (Video 27.1). (▸ https://doi.org/10.1007/000-2vp)

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Finally the area of the remaining ovarian tissue is assessed for bleeding. In the majority of cases there is no need to suture the margins of the remaining ovarian tissue.

27.5 Postoperative Care The transurethral catheter is immediately removed after the procedure. Analgetic therapy is tailored to the patients needs. At follow up an ultrasound should be performed to visualize the remaining ovary 6 weeks postoperatively. The presentation of follicular cysts indicate normal ovarian function.

27.6 Pearls/Tips & Tricks 1. It is important to keep intraoperative malignancy criteria in mind prior to any attempt of tissue sparing removal of an ovarian mass. 2. Thorough inspection and superficial incision of the capsule at the beginning of the procedure 3. The remaining ovary is opened like a book to facilitate the cyst/mass excision 4. Meticulous dissection takes time 5. Use an endobag whenever possible despite negative tumor markers and absent signs of malignancy on imaging

27.7 Pitfalls & Ways to Avoid 1. Assessment of serologic tumor markers is mandatory prior to any surgical procedure 2. Ovarian preservation should be a priority but without sacrificing oncologic principles 3. If ovarian sparing resection at the time of torsion is not possible, a staged procedure with re-evaluation of ultrasound and/or MRI and serologic tumor markers after 4–6 weeks is recommended to avoid unnecessary resection of the ovary (Video 27.1)

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Milestone 27.2  Endobag placement

Milestone 27.4  Circumferential dissection of the ovarian mass

Milestone 27.3  Superficial incision of the ovarian capsule

Milestone 27.5  Removal of the ovarian mass in an endoscopic retrieval bag

References 1. Papic JC, Finnell SM, Slaven JE, Billmire DF, Rescorla FJ, Leys CM. Predictors of ovarian malignancy in children: overcoming clinical barriers of ovarian preservation. J Pediatr Surg. 2014;49:144–8. 2. Aldrink JH, Gonzalez DA, Sales SP, Deans KJ, Besner GE, Hewitt GD.  Using quality improvement methodology to improve ovarian salvage for benign ovarian masses. J Pediatr Surg. 2018;53:67–72. 3. Chabaud-Wiliamson M, Netchine I, Fasola S, Larroquet M, Lenoir M, Patte C, Benifla JL, Coulomb-L’hermine A, Grapin C, Audry G, Auber F. Ovarian-sparing surgery for ovarian teratoma in children. Pediatr Blood Cancer. 2011;57:429–34. 4. Oltmann SC, Garcia N, Barber R, Huang R, Hicks B, Fischer A.  Can we preoperatively risk stratify ovarian masses for malignancy? J Pediatr Surg. 2010;45:130–4.

5. Childress KJ, Perez-Milicua G, Hakim J, Adeyemi-Fowode O, Bercaw-Pratt JL, Santos XM, Dietrich JE.  Intraoperative rupture of ovaian dermoid cysts in the pediatric and adolescent population: should this change your surgical management? J Pediatr Adolesc Gynecol. 2017; https://doi.org/10.2016/j.jpag.2017.03.139. 6. Renaud EJ, Somme S, Islam S, Cameron DB, Gates RL, Williams RF, Jancelewicz T, Oyetunji TA, Grabowski J, Diefenbach KA, Baird R, Arnold MA, Lal DR, Shelton J, Guner YS, Gosain A, Kawaguchi AL, Ricca RL, Goldin AB, Dasgupta R.  Ovarian masses in the child and adolescent: an American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review. J Pediatr Surg. 2019;54(3):369–77.

Laparoscopic-Assisted Mobilization and Resection of a Sacrococcygeal Teratoma

28

Jan Goedeke and Oliver. J. Muensterer

28.1 The Sacrococcygeal Teratoma and Indications for a Laparoscopic Approach Sacrococcygeal teratomas (SCTs) are the most common extragonadal germ cell tumors in children. The incidence is approximately 1 in 35,000 newborns, with females accounting for 75% of cases [1]. Most pediatric surgeons classify SCTs according to Altman [2]. Type I and II have predominant extrapelvic components. Type III and IV show a predominant intrapelvic location (Fig. 28.1). From personal experience and that of other surgeons [3] the laparoscopic approach offers two main advantages. On the one hand, it enables safe and secure interruption of the median sacral artery (main supplying tumor vessel), so that the risk of lifethreatening hemorrhage during surgery will be lowered. On the other hand, it allows the safe dissection of the supralevatoric tumor mass, so that final tumor resection in prone jackknife position will be simplified. The time required for laparoscopy is usually saved during the final resection, so that the overall operation time is not prolonged and even shortened in the hands of the experienced surgeon. The laparoscopic approach may thus replace the still widely used technique of abdominal approach through a lower transverse muscle-sparing incision. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_28. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. J. Goedeke (*) Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany e-mail: [email protected] O. J. Muensterer Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

28.2 Preoperative Workup and Considerations Preoperative workup should focus on evaluating the degree of pelvic and abdominal extension in order to classify the tumor type and to plan the surgical procedure. If an ultrasound is not conclusive enough, we also carry out an MRI scan of the pelvis. In our opinion the latter is especially useful in older children with Altman type II–IV tumors and expected suprapelvic tumor spread to clarify the exact relationship to the surrounding tissue and the spinal canal, or if there is suspicion of malignancy (Fig. 28.2). Especially in large Altman type 1 tumors preoperative cardiologic workup and an echocardiography is mandatory (Fig. 28.3). Any further imaging might be performed postoperatively if necessary. In addition to imaging procedures the serum alpha-1-­ fetoprotein (AFP) is preoperatively required. An elevated serum alpha-fetoprotein level is commonly associated with malignancy (yolk sac or endodermal sinus tumor, embryonal carcinoma, or undifferentiated germ cell tumor) [1]. One must always keep in mind the different age-related and therefore normal increased AFP values in young children especially in the newborn period.

28.3 Anesthetic Considerations Older children should receive an antegrade bowel preparation to decompress the large intestine. This provides a better exposure during laparoscopy. In newborns a colon washout with saline may be performed on the OR table. Prior to any surgical procedure it is necessary to stabilize the patients hemodynamically. Especially newborn babies with huge Type I SCTs might be hemodynamically unstable and need inotropic medication and neonatal intensive care. SCT resection is typically performed under general endotracheal anesthesia. Additional epidural anesthesia

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_28

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152 Fig. 28.1 Altman classification of sacrococcygeal teratomas, adopted by the American Academy of Pediatrics (AAP), based on the degree of intrapelvic extension

J. Goedeke and O. J. Muensterer I

II

III

IV

can be given in selected cases except in the presence of coagulopathy. Since children are often newborns with large tumors and high vascular tumor perfusion anesthesia should be performed by experienced pediatric anesthesiologists. Severe intraoperative bleeding is rare, but having blood available is advisable due to the complex nature of the procedure. At least two peripheral intravenous catheters should be available. Hypothermia should be avoided. A nasogastric tube can be advantageous when there is an important intra-abdominal extension of the tumor or when the small bowel is distended. A urinary catheter is not required per se in type I tumors in which only the median sacral artery has to be interrupted laparoscopically. The bladder should, however, be manually emptied. In type II, III, and IV lesions, a urinary catheter should be inserted. It is advantageous to do that periopera-

tively after prepping and draping. When the bladder obscures the view, it can be emptied perioperatively with a syringe. Perioperative antibiotic prophylaxis should be given according to hospital policy.

28.4 Operative Technique 28.4.1 Equipment • • • • • •

4 trocars (3 mm or 5 mm) 3 or 5 mm 30° laparoscope 3 mm Maryland dissector 3 mm atraumatic grasper 3 mm Metzenbaum scissors Hegar dilators on different sizes, depending on the size of the child

28  Laparoscopic-Assisted Mobilization and Resection of a Sacrococcygeal Teratoma

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• 5 mm laparoscopic sealer/divider, for instance LigaSure™ • 2–0 braided polyglactin or polydioxanone suture (for traction suture on uterus in females transabdominally) • The median sacral artery may be closed in different ways (clipping, ligation, coagulation with monopolar, bipolar or vessel sealer, for instance LigaSure™) so that, as appropriate, additional equipment may become necessary.

28.4.2 Positioning

Fig. 28.2  1 yoF, MRI (t2_tse_sag_320_p2) shows a characteristic supra- and infralevatoric mass (Altman Type III)

The patient is placed in a supine Trendelenburg position at the lower end of the operating table. The patient should be secured by tape to the bed to allow for safe positioning and rotating to both sides during the procedure if necessary. The surgeon stands on the right side of the patient, the assistant on the left side. The scrub nurse stands to the right of the surgeon. The monitor is at the lower end of the table (Fig. 28.4). Babies can also be placed transversally at the end of the operating table. In this case the surgeon stands at the patient’s head with the assistant on the left side and the scrub nurse on the right side. The monitor stands opposite to the surgeon at the patient’s feet (Fig. 28.4). The abdomen is prepped and draped from the nipples to the legs. The feet are separately draped as for surgery for anorectal malformation (ARM). Underneath the anus, small drapes are placed which are removed when they become contaminated with rectal effluent. For the final conventional open tumor resection the patient is turned around in a prone jackknife position after completion of the laparoscopy. Thereafter, the patient is prepped and draped locally from the lower back to the thighs again. In difficult cases, both surgical steps can be combined with each other, similar to ARM surgery, and the patient can be turned around, leaving the laparoscopic trocars in place, and also turned back.

28.4.3 Trocar Placement

Fig. 28.3  Newborn with characteristic mass protruding from the sacral region (Altman Type I) (It is an example and a different patient than shown in the video)

The umbilical port site is injected with local anesthesia (0.25% bupivacaine) at the beginning and the 3 or 5  mm umbilical trocar is inserted in an open fashion. In newborns it is important to avoid injury to the umbilical vessels. After transumbilical skin incision a small umbilical fascial defect is usually present, allowing introduction of an overhold clamp that can guide the fascial incision. The capnoperito-

154 Fig. 28.4  Positioning of patient, surgeons and monitors

J. Goedeke and O. J. Muensterer

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

neum is insufflated using a pressure of 8–10  mmHg and a flow of 2 l/min. During the procedure, the insufflation pressure can be increased temporarily to provide sufficient working space. Under laparoscopic vision 3 additional trocars are placed (5 mm: surgeon’s right hand, pararectally at umbilical level on the right in babies or lower in older children; 3 mm: surgeon’s left hand, midepigastrium in babies, lower down and more to the left in older children; 3 mm: assistant, pararectally at umbilical level on the left in babies or lower in older children) (Fig. 28.5). After trocar placement the patient is positioned in Trendelenburg position. This positioning can be advanced during the procedure if the patient tolerates this hemodynamically. It helps the small bowel to fall away from the operative field.

Legend

Working trocars Endoscope trocar

Fig. 28.5  Positioning of the trocars

28  Laparoscopic-Assisted Mobilization and Resection of a Sacrococcygeal Teratoma

28.4.4 Operative Milestones The laparoscopic part of the SCT operation can be divided into two main steps: 1. Ligation of the median sacral artery 2. Dissection of the intrapelvic portion of the SCT For right-handed surgeons, it is best to approach the SCT from the right. In females the first step is usually to place a transcutaneous traction suture through the uterus (2–0 braided polyglactin suture with huge semicircular needle) in order to pull it up anteriorly for a better small pelvic overview (Milestone 28.1). After that the rectum is grasped by the assistant using the left hand with a 3 mm atraumatic grasper and pulled to the left. The surgeon gets a good view of the peritoneum in between the rectum and the pelvic rim on the right and the peritoneum is opened with the 5  mm sealer device (Milestone 28.2). The median sacral artery is often directly visible because of its larger size and pulsations. It arises

Milestone 28.1  The uterus (in females) is attached to the abdominal wall (Video 28.1 Laparoskopic-assisted SCT Goedeke Muensterer 08312018). (▸ https://doi.org/10.1007/000-2vq) Milestone 28.3  The median sacral artery has been clearly identified, freed and it is interrupted with 5 mm laparoscopic sealing device

155

posterior to the abdominal aorta and superior to its bifurcation and descends in the middline in front of the fourth and fifth lumbar vertebrae, the sacrum and coccyx, ending in the glomus coccygeum. The artery needs to be freed from surrounding loose areolar tissue for about 1–1.5 cm. After that it can be ligated in several ways. In our department we use a 5 mm laparoscopic sealing device (Milestone 28.3). The dissection of the intrapelvic portion of the SCT is relatively simple once the right plane is identified. For right-­ handed surgeons, the best approach to the SCT is still from the right, while the assistant still pulls the rectum to the left. The already opened pelvic peritoneum is opened slightly further towards the pelvic floor and the tumor is progressively exposed circularly until the pelvic floor muscles can be clearly identified. For this procedure we usually use a 5 mm laparoscopic sealer system, as we can dissect and coagulate tissue with the same device in the right hand, and a 3 mm atraumatic grasper or Maryland dissector in the left hand (Milestone 28.4).

Milestone 28.2  The pararectal space is entered on the right side

156

Milestone 28.4  The tumor is dissected circularly. It sits in the pelvis behind the rectum

When the intra-abdominal extension of the SCT is large and mainly cystic, additional working space can be created by fine-needle aspiration of the larger cysts. However, only clear cysts should be aspirated. After circular mobilization the last part of the tumor is still firmly adherent to the coccyx. The laparoscopic part of the operation is now terminated, trocars and traction sutures are removed, incisions closed and the operation is continued in the well-known classic way. In difficult cases, the surgical steps can be combined with each other, similar to ARM surgery, and the patient can be turned around for final tumor resection, leaving the laparoscopic trocars in place, and also turned back.

J. Goedeke and O. J. Muensterer

sected. Care must be taken to identify and ligate the median sacral artery if not completed during laparoscopy. The sacrococcygeal joint is divided with heavy scissors or electrocautery (often possible), leaving the coccyx attached to the teratoma. The final wound closure begins with the reapproximation of the midline levator complex to the presacral fascia with interrupted sutures (2–0 or 3–0 polyglactin suture). At this time a passive drainage is not mandatory necessary but it may be considered in cases of increased secretion to avoid seroma formation. We usually use a quadrain drainage (Pajunk Quadrain Drainage Katheter 10F or 12F) for this purpose. Finally the gluteal muscles are reconstructed in the midline (3–0 polyglactin suture), and excessive skin is excised. The subcutaneous tissue is closed with absorbable sutures (4–0 polyglactin suture), followed by subcuticular skin closure (5–0 Poliglecapron 25-Copolymer) and steristrip dressing, to reduce tension on the scar.

28.6 Postoperative Care

The nasogastric tube is removed in the OR. Antibiotic prophylaxis during postoperative care is not mandatory if not given for other reasons. Surgical drains (if placed) should be removed when drainage is minimal within the first postoperative days. The urinary catheter is often kept for several days due to simplify care and prevent wound ingestion in the early healing process through urine in diapers. Initiation of enteral feeds can be started, once bowel function returns. The AFP level should be determined early postoperatively to have a baseline for follow-up observations. Patients may be fully mobilized. The oncological follow-up depends on the final pathology 28.5 Final Tumor Resection via Posterior report. Functional complications following classic surgical resecSacrococcygeal Approach tion of SCT include involuntary bowel movement, fecal soilThe patient is turned around in a prone jackknife position ing or constipation and urinary incontinence (up to 50%) or after completion of the laparoscopy. After prepping and urinary tract dysfunction secondary to pelvic nerve injury draping locally from the lower back to the thighs an arc-­ during pelvic dissection [4]. shaped skin incision is made with the apex focused on the Regarding laparoscopically assisted tumor resection, sacrococcygeal joint. The incision sweeps inferolaterally individual published case reports suggest there could be betaround the external tumor mass to encompass the mass and ter gastrointestinal and urological long-term results, but abnormal skin. Using electrocautery the dissection is car- there is no published study yet that does compare the classiried down through the subcutaneous tissue to the tumor cal tumor surgery and the laparoscopic approach. capsule posteriorly and gluteal muscles laterally. The gluteal muscles are typically splayed over the SCT and should be retracted laterally to allow mobilization of the tumor 28.7 Pearls/Tips & Tricks with blunt and sharp dissection. Care should be taken to avoid excessive traction on the levator complex. A hegar 1. Sufficient preoperative imaging is crucial to plan the surgical procedure, to determine resection borders, and to dilator may be inserted into the rectum to guide the separaexclude unexpected findings, such as myelomeningocele, tion of the tumor from the rectum. The posterior dissection spinal defects, and urinary tract obstruction. is continued down to the coccyx and the coccyx is dis-

28  Laparoscopic-Assisted Mobilization and Resection of a Sacrococcygeal Teratoma

2. Early laparoscopic identification and ligation of the median sacral artery does enable early vascular control and does minimize intraoperative blood loss. 3. An arc-shaped skin incision with the apex focused on the sacrococcygeal joint might improve the wound healing as the tissue perfusion is not as limited as in sharp corner (90°) incisions. The exposition of the operative field remains the same. 4. Careful dissection closely adjacent to the tumor capsule may minimize inadvertent injury to the sympathetic and parasympathetic pelvic plexus and may help to reduce long-term urinary, fecal, and possible sexual dysfunction. 5. It is advisable to identify the ureters (at least the right ureter) safely before any dissection in the pelvis to avoid accidental and unnecessary ureteral injury. 6. A Hegar dilator may be inserted into the rectum to guide the separation of the tumor from the rectum.

28.8 Pitfalls & Ways to Avoid 1. When the intra-abdominal extension of the SCT is large and mainly cystic, additional working space can be created by fine-needle aspiration of the larger cysts. Only clear cysts should be aspirated. 2. If during sacral tumor resection mass bleeding appears and if the sacral artery is not sufficiently ligated, the patient should be positioned directly in the supine posi-

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tion followed by an emergency laparotomy, to identify and ligate the median sacral artery sufficiently. This will usually stop the massive bleeding. 3. The tumor forms from remnants of the primitive streak (or from primordial germ cells) at the tip of the coccyx. It is recommended to resect the coccyx together with the adherent tumor during the tumor resection to prevent an increased tumor recurrence rate. Incomplete resection and malignant histology are considered as main risk factors for recurrence [5].

References 1. Rescorla FJ.  Pediatric germ cell tumors. Semin Pediatr Surg. 2012;21(1):51–60. 2. Altman RP, Randolph JG, Lily JP.  Sacrococcygeal teratoma, American Academy of Pediatrics Surgical Section survey. J Pediatr Surg. 1974;9:389–98. 3. Huy T, Osei H, Munoz Abraham AS, Damle R, Villadona GA.  Laparoscopic ligation of middle sacral artery and dissection of sacrococcygeal teratoma to decrease intraoperative hemorrhagic risk. WebSurgcom 2019;19(01). http://websurg.com/doi/ vd01en5495. Last check on December 21st, 2019. 4. Rintala R, Lahdenne P, Lindahl H, Siimes M, Heikinheimo M. Anorectal function in adults operated for a benign sacrococcygeal teratoma. J Pediatr Surg. 1993;28(9):1165–7. 5. Derikx JP, De Backer A, van de Schoot L, Aronson DC, de Langen ZJ, van den Hoonaard TL, Bax NM, van der Staak F, van Heurn LW. Factors associated with recurrence and metastasis in sacrococcygeal teratoma. Br J Surg. 2006;93(12):1543–8.

Part VI Hernias

Laparoscopic Herniorrhaphy

29

Illya Martynov and Martin Lacher

29.1 Indications for Laparoscopic Approach to Inguinal Hernia The indications for laparoscopic inguinal hernia repair are the same as for the open approach. Several published randomized controlled trials comparing laparoscopic and open techniques suggest an equivalent operating time for unilateral hernias [2, 3, 5, 6] and significantly faster operating times for bilateral hernias [1, 2, 6]. Moreover, the recurrence rate [3, 6] and rate of testicular atrophy [4, 6] has been proven to be equivalent.

29.2 Preoperative Workup and Considerations The diagnosis of inguinal hernias is typically based on history of a visible commonly intermittent swelling or bulge in the inguinoscrotal region in boys or inguinolabial region in girls, as well as physical examination revealing groin or scrotal enlargement. A urinary catheter is not necessarily inserted, but an empty bladder aids with laparoscopic inguinal exposure. Preoperative enemas are unnecessary, and we do not generally give perioperative antibiotics.

29.3 Anesthetic Considerations Laparoscopic inguinal hernia repair is typically performed under general anesthesia and endotracheal intubation. An elective operation is usually performed in an ambulatory setting for otherwise healthy infants older than 6  months. Infants with prematurity or associated disorders should be observed after operation for 24 h for signs of postoperative apnea if their age is less than 60 postconceptional weeks. A naso- or orogastric tube is placed to decompress the stomach for the duration of the procedure. There is no need for epidural or spinal anesthesia.

29.4 Operative Technique 29.4.1 Equipment • • • • • • •

3 or 5 mm optical trocar Atraumatic grasper 22G Syringe-needle 18G/80mm-Touhy needle Non-absorbable 4-0 polypropylene suture 2-0 polyglycolic acid suture 5-0 poliglecaprone suture

29.4.2 Positioning

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_29. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. I. Martynov · M. Lacher (*) Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]

Supine positioning with arms tucked to side and legs spread slightly apart. The operator position stands on the ipsilateral side, the first assistant on the contralateral side of the hernia. The monitor is placed towards the infant’s feet to have the open processus vaginalis in line between the camera and the monitor. The scrotum should be prepped and exposed to have the possibility to pull on the testicle in a sterile fashion during dissection over the vas (Figs.  29.1 and 29.2).

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_29

161

162 Fig. 29.1  Positioning of patient, surgeons and monitors

I. Martynov and M. Lacher Surgeon (ipsilateral side)

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse Instrument table

Fig. 29.2  Trocars in place

29.4.3 Trocar Placement A 3 or 5 mm 30° scope is introduced through the umbilicus, and a capnoperitoneum is established. A 2 mm laparoscopic grasper, placed laterally through a stab incision on the contralateral mid abdomen is used to manipulate the peritoneum near the inguinal ring (Fig. 29.2).

29.4.4 Operative Milestones (Video 29.1) The operation begins with identification of the internal inguinal ring and confirmation of a patent processus vaginalis. Slight Trendelenburg (head-down) positioning aids with exposure. The location of the inguinal incision is selected with the help of the introduction of a syringe-needle in the 12 o’clock position over the internal ring. After removal of the needle, a 1-mm needle stab incision is created, and a Touhy needle is inserted into the subperitoneal space directly over the internal ring (Milestone 29.1). It is then advanced extraperitoneally on the medial side of the ring. When it is ­difficult to separate the vas deferens from peritoneum, a hydrodissection technique is performed by infusing 1–2 cc of normal saline solution into

Milestone 29.1  Via a 1-mm needle stab incision a Touhy needle is inserted into the subperitoneal space directly over the internal ring (Video 29.1 Laparoscopic hernia repair). (▸ https://doi.org/10.1007/000-2vr)

the preperitoneal space through the sheath of the Touhy needle as a jet. Also, the grasping forceps assists with the procedure by providing counter traction on the peritoneum.

29  Laparoscopic Herniorrhaphy

163

Milestone 29.2  The Tuohy needle is bluntly advanced over the gonadal vessels and vas deferens directly under the peritoneum (remaining extraperitoneal until half of the sac has been surrounded Milestone 29.4  The Tuohy needle is then passed through the loop of the first suture (*). The second polypropylene suture (#) is introduced through the barrel of the Tuohy needle into peritoneal cavity

Milestone 29.3  A tightly kinked non-absorbable 4-0 loop of polypropylene suture is threaded through the barrel of the Tuohy needle creating an intraperitoneal loop

The Tuohy needle is bluntly advanced over the gonadal vessels and vas deferens directly under the peritoneum (remaining extraperitoneal until half of the sac has been surrounded) (Milestone 29.2). It is relatively straightforward to find the plane between these structures and the hernia sac, ensuring that they are excluded from the repair. In girls, the Touhy needle is advanced under the round ligament of the uterus and the ligament is incorporated into the closure. Once the needle successfully advanced over the above structures and the tip has reached the base of the sack (6 o’clock position), the peritoneal layer is punctured and the tip of Touhy needle enters the peritoneal cavity. A tightly kinked non-absorbable 4-0 loop of polypropylene suture is threaded through the barrel of the Tuohy needle creating an intraperitoneal loop (Milestone 29.3). While the end of the loop is secured with the grasper, the Touhy needle

Milestone 29.5  The first (*) (short) suture loop is pulled out through the abdominal wall by picking up the second suture (#) loop therefore encircling the hernia sack

is withdrawn with the loop remaining in the abdomen. The empty Tuohy needle is reinserted through the same puncture site to dissect anterolateral to the inguinal ring and exits into the peritoneal cavity through the same perforation performed for the first ligature. The Tuohy needle is then passed through the loop of the first suture. The second polypropylene suture is introduced through the barrel of the Tuohy needle into peritoneal cavity (Milestone 29.4). Subsequently, the needle is removed leaving both sutures intraperitoneally. Finally, the first (short) suture loop pulls the second suture loop out through the skin incision, therefore leaving the latter encir-

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I. Martynov and M. Lacher

2. Prior to insertion of the duplicated non-absorbable 4-0 polypropylene suture into the Tuohy needle the end of the loop of is tightly squeezed and kinked at its end. This facilitates the maneuver to advance the long suture loop through the sheath of the epidural needle into abdominal cavity in an antegrade manner. 3. The dissection over the vas deferens is facilitated by a gentle pull on the testicle by the assistant. 4. Polypropylene sutures are suitable; some authors exchange the polypropylene suture by a polyester fiber prior to tying the knots at the end of the operation. 5. The residual CO2 in the cavity tunica vaginalis can be eliminated by puncture in the scrotum. However, if resolves spontaneously within a few hours. 6. The laparoscopic technique is especially suitable for hernias in premature children or recurrent hernias as the dissection from inside the abdomen is much easier as dissection of the hernia sac from the outside. Milestone 29.6  Both corresponding ends of the sutures are tied extracorporeally completing an extraperitoneal high ligation of the sac by two polypropylene 4-0 sutures

cling the hernia sack (Milestone 29.5). Both corresponding ends of the sutures are tied extracorporeally completing an extraperitoneal high ligation of the sac by two polypropylene 4-0 sutures (Milestone 29.6). The knots are buried beneath the skin. Prior to cutting the excess ligature, the surgeon should retract the skin upward to avoid trapping of the skin into the knot. The instruments are removed, and the abdomen is allowed to desufflate. Steristrips or skin glue is all that are required for skin closure. A metachronic contralateral hernia may be simultaneously repaired by using the same technique in a mirror-type fashion if found during exploration.

29.5 Postoperative Care An immediate return to normal activities without restrictions is allowed. The procedure may be performed in an outpatient setting. All patients or their parents are queried at the first postoperative visit regarding the extent of postoperative pain, the level of activity, and the need for analgesics.

29.7 Pitfalls & Ways to Avoid 1. The dissection around the medial aspect of the internal inguinal canal is the most crucial. At this location a so called “skip lesion” may occur meaning that the Tuohy needle enters the peritoneal cavity and goes back in the retroperitoneum without notice of the surgeon. The hernia sac is then not encircled circumferentially; therefore recurrence will be most likely. 2. The medial side the epigastric vessels may be accidently be lacerated. In this case, remove the instruments, desufflate the capnoperitoneum and provide digital pressure on the base of the epigastric vessels (medial inguinal region) percutaneously for a few minutes—the bleeding will stop and hematoma formation will be minimized. 3. Use the hydrodissection sparingly and only directly at the vas or vessels. Injecting too much fluid initially will cause peritoneal redundancy that is hard to manage. 4. Counter-tension of the peritoneal layer by the grasping forceps prevents skip lesions and peritoneal folds. 5. To avoid injuries of surrounding structures and for accurate subperitoneal needle dissection the tip of the Tuohy should be constantly visible through the peritoneum.

29.6 Pearls/Tips & Tricks

References

1. The surgeon should stand on the side of the hernia. In case of bilateral hernia repairs he surgeon should change sides.

1. Celebi S, Uysal AI, Inal FY, Yildiz A.  A single-blinded, randomized comparison of laparoscopic versus open bilateral hernia repair in boys. J Laparoendosc Adv Surg Tech A. 2014 Feb;24(2):117–21.

29  Laparoscopic Herniorrhaphy 2. Chan KL, Hui WC, Tam PK. Prospective randomized single-center, single-blind comparison of laparoscopic vs open repair of pediatric inguinal hernia. Surg Endosc. 2005;19(7):927–32. 3. Koivusalo AI, Korpela R, Wirtavuori K, Piiparinen S, Rintala RJ, Pakarinen MP.  A single-blinded, randomized comparison of laparoscopic versus open hernia repair in children. Pediatrics. 2009;123(1):332–7. 4. Nah SA, Giacomello L, Eaton S, de Coppi P, Curry JI, Drake DP, Kiely EM, Pierro A.  Surgical repair of incarcerated ingui-

165 nal hernia in children: laparoscopic or open? Eur J Pediatr Surg. 2011;21(1):8–11. 5. Saranga Bharathi R, Arora M, Baskaran V. Pediatric inguinal hernia: laparoscopic versus open surgery. JSLS. 2008;12(3):277–81. 6. Shalaby R, Ibrahem R, Shahin M, Yehya A, Abdalrazek M, Alsayaad I, Shouker MA. Laparoscopic hernia repair versus open Herniotomy in children: a controlled randomized study. Minim Invasive Surg. 2012;2012:484135.

Laparoscopic Epigastric Hernia Repair

30

Anne-Sophie Holler and Oliver J. Muensterer

30.1 Indications for the Laparoscopic Approach to Epigastric Hernia Epigastric hernias present as an indolent or painful swelling between the xiphoid and the umbilicus. As they rarely resolve by themselves, repair is indicated in all cases especially when they are symptomatic [1]. The laparoscopic approach is indicated in those epigastric hernias in which the fascial defect is located 40 mm or further (some authors recommend 15 mm) from the umbilicus [2, 3]. Hernias that are closer to the navel are more difficult to approach laparoscopically as the working space and the angle to the upper abdominal wall is very limited [2, 3]. In such cases, an open approach with an incision at the umbilicus with subsequent tunneling subcutaneously upward to the hernia may be easier to perform with comparable cosmetic results. A SIPES (single-incision pediatric endosurgical) technique is feasible in most cases.

30.2 Preoperative Workup and Considerations Epigastric hernias are diagnosed by physical examination. On examination, either a painful or indolent epigastric mass somewhere midline between the umbilicus and the xiphoid can be palpated [1]. Usually no further diagnostic adjuncts are needed. In exceptional cases, when discrimination Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_30. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. A.-S. Holler, MD (*) · O. J. Muensterer, MD, PhD Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

towards other entities as lipoma, fibroma and neurofibroma is difficult, ultrasonography may be performed [4]. It is essential to mark the hernia preoperatively when the child is awake as the hernia can be difficult to palpate once the patient is under general anesthesia. There is no need for perioperative antibiotic prophylaxis.

30.3 Anesthetic Considerations Laparoscopic epigastric hernia repair is performed under general anesthesia and endotracheal intubation. For intra- and postoperative pain control, local anesthetics such as bupivacaine 0.25% should be used for infiltration of the trocar sites. Decompression of the stomach with a nasogastric tube is advisable. In otherwise healthy children, the procedure can be performed in an outpatient setting.

30.4 Operative Technique 30.4.1 Equipment • 3 × 3-mm trocars or 1 × 5 mm trocar and 1 × 3 mm trocar for the SIPES technique • 3-mm 30° laparoscope or 5-mm 30° laparoscope • 3-mm Monopolar hook cautery • 3-mm Maryland dissector • 2-0 braided polyglactin suture • cyanoacrylate tissue adhesive For intracorporeal suturing: • 3-mm needle holder • 3-mm Metzenbaum scissors • 2-0 braided glycolide, dioxanone and trimethylene carbonate absorbable suture For percutaneous technique: • 17-g epidural (Tuohy) needle • 4-0 braided polypropylene suture

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_30

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A.-S. Holler and O. J. Muensterer

30.4.2 Positioning The patient is placed in supine position. For the SIPES approach, it is helpful to put a roll under the lumbar spine [3]. The surgeon stands on the patient’s left side, the assistant on the patient’s right side. The monitor is positioned at the patient’s head (Fig. 30.1).

30.4.3 Trocar Placement The child is prepped from the nipple line to the pubis. The camera trocar is placed at the umbilicus. A capnoperitoneum is established. One working trocar is introduced in the left lower abdomen. If needed a second trocar is added in a triangulated fashion on the right lower abdomen [2, 5]. The procedure can also be performed in single incision technique Fig. 30.1  The patient is placed in supine position. The surgeon stands on the patient’s left side, the assistant on the patient’s right side

(SIPES) by introducing the camera trocar through the umbilicus and adding a second trocar through the umbilicus adjacent to the first [3] (Fig. 30.2).

30.4.4 Operative Milestones First, the abdominal wall is inspected by angling the 30° laparoscope upward. In most cases, the hernia is found somewhere midline between the umbilicus and the xiphoid. Pushing down on the abdominal wall at the preoperatively marked hernia site facilitates identification of the hernia. In some cases, partial excision of the falciform ligament is advisable [1, 3]. Once the hernia site is localized, the peritoneum is incised using monopolar hook cautery and the preperitoneal fat is dissected off bluntly until the fascial defect is visualized (Milestone 1). Any incarcerated fat is now

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

Fig. 30.2  Trocar placement

Legend Working trocar Endoscope trocar

3 Trocar Approach

SIPES Technique

30  Laparoscopic Epigastric Hernia Repair

reduced and pulled back into the abdominal cavity (Milestone 2; Fig.  30.3). The fascial defect is now clearly visible (Milestone 3; Fig. 30.4). Closure of the fascial defect can be performed either by intracorporeal suturing or by a percutaneous suturing technique using a Tuohy needle. In the first case, a needle is inserted directly from the skin through the defect into the abdominal cavity. Suturing is performed in a running fashion closing the defect longitudinally (Milestone 4a; Fig.  30.5). Sometimes it is helpful to push down on the abdominal wall to create a better angle for suturing. Also, using a barbed suture limits the need for knot tying and therefore speeds up the procedure. When using the percutaneous suturing technique the exact needle entry point on the skin is determined by using a subcutaneous needle on a 5 ml syringe filled with normal saline solution. A 2  mm stab incision is created on the

Fig. 30.3 Milestone 2: Any incarcerated preperitoneal fat is removed  (Video 30.1 Laparoscopic epigastric hernia repair). (▸ https://doi.org/10.1007/000-2vs)

Fig. 30.4  Milestone 3: The fascial defect is clearly visible

169

abdominal wall and through this incision the Tuohy needle is introduced into the abdominal cavity on one lateral side of the defect. A 4-0 polypropylene suture loop is introduced through the Tuohy needle into the abdominal cavity. Then the Tuohy needle is removed leaving the suture loop in place. The needle is reinserted through the same skin incision perforating on the contralateral side of the fascial defect. The former introduced suture loop is now “lassoed” around the needle and pulled tight (Milestone 4b, Fig. 30.6). A second suture loop is passed through the needle into the abdominal cavity and the needle is removed. By pulling on the first suture, the second one is pulled around the defect and ­withdrawn to the outside. Knotting is performed extracorporeally and the knot is pushed down to the fascia in the subcutaneous plane. Depending on the hernia size, one or more sutures may be required.

Fig. 30.5  Milestone 4a: The fascial defect is completely closed using a running suture

Fig. 30.6  Milestone 4b: The first suture loop is introduced into the abdominal cavity and lassoed by the Tuohy needle

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When the defect is closed tightly all instruments are removed and the capnoperitoneum is desufflated. The fascia at the umbilical trocar site is closed with 2-0 polyglactin sutures. The skin is closed administering cyanoacrylate tissue adhesive (Video 30.1).

30.5 Postoperative Care Laparoscopic epigastric hernia repair may be performed as an outpatient procedure. All patients are discharged on oral analgesics. Return to normal activity is possible immediate after surgery. Nevertheless, we recommend refraining from athletic activities for 1–2 weeks.

30.6 Pearls/Tips & Tricks 1. The hernia should be marked preoperatively when the child is awake. 2. Gently pushing on the side of the hernia from the outside on the abdominal wall facilitates identification of the fascial defect. 3. Pushing down the abdominal wall when suturing additionally provides better visualization and better accessibility.

A.-S. Holler and O. J. Muensterer

4. For the SIPES approach, the percutaneous suturing technique is recommended. 5. Intracorporeal suturing is simpler if a barbed suture is used.

30.7 Pitfalls & Ways to Avoid 1. Hernias that are closer than 4–5 cm to the umbilicus are difficult to approach by the laparoscopic technique and therefore careful patient selection is crucial.

References 1. Coats RD, Helikson MA, Burd RS. Presentation and management of epigastric hernias in children. J Pediatr Surg. 2000;35(12):1754–6. 2. Moreira-Pinto J, Correia-Pinto J.  Scarless laparoscopic repair of epigastric hernia in children. Hernia. 2015;19:623–6. https://doi. org/10.1007/s10029-­015-­1369-­2. 3. Babsail AA, Abelson JS, Liska D, Muensterer OJ.  Single-­ incision pediatric endosurgical epigastric hernia repair. Hernia. 2014;18(3):357–60. https://doi.org/10.1007/s10029-­014-­1235-­7. 4. Spangen L. Ultrasound as a diagnostic aid in ventral abdominal hernia. J Clin Ultrasound. 1975;3(3):211–3. 5. Albanese CT, Rengal S, Bermudez D. A novel laparoscopic technique for the repair of pediatric umbilical and epigastric hernias. J Pediatr Surg. 2006;41(4):859–62.

Part VII Urology

Laparoscopic Pyeloplasty

31

Gabriel Goetz, Illya Martynov, and Martin Lacher

31.1 Indications for Laparoscopic Approach to Ureteropelvic Junction Obstruction Pyeloplasty is indicated in children with ureteropelvic junction obstruction, which is the most common cause of pediatric hydronephrosis. The etiology includes intrinsic obstruction due to stenosis of the pyeloureteric junction (scarring, hypoplasia) or secondary causes like aberrant lower pole vessels or kidney abnormalities (horseshoe, pelvic or duplex kidney). Symptomatic patients (pain, urinary tract infections), those with impaired renal function (10% or obstructive pattern on diuretic renograms require surgical intervention. The indications for laparoscopic pyeloplasty are the same as for the open approach. Several published studies comparing laparoscopic and open techniques suggest a shorter length of hospital stay [1–4], lower analgesia requirement [4, 5] and an equivalent success and complication rate [1, 3–6]. The laparoscopic approach is even viable for redo pyeloplasty [7].

31.2 Preoperative Workup and Considerations Hydronephrosis is typically seen on prenatal ultrasound and confirmed postnatally. Especially in older children, evaluation of intermittent flank pain or urinary tract infection may reveal ureteropelvic junction obstruction. Mercaptoacetyltriglycine Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_31. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. G. Goetz · I. Martynov (*) · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]

(MAG3) diuretic renography is needed in most cases to assess kidney function and diagnose those with functional significant obstruction. Preoperative enema and a Foley catheter to empty the bladder facilitate the intraoperative working space. Another advantage of the urinary catheter is to confirm the regular placement of the intraoperatively inserted double-J ureteric stent after filling the bladder with blue dye. Administration of perioperative antibiotics is warranted.

31.3 Anesthetic Considerations Laparoscopic pyeloplasty is performed under general endotracheal anesthesia. A nasogastric tube should be in place for the duration of the procedure and removed afterward. Two peripheral intravenous catheters are sufficient without any need for central venous line. Relevant blood loss is not expected. Especially in infants prevention of hypothermia has to be addressed.

31.4 Operative Technique 31.4.1 Equipment • • • • • • • •

5 or 10 mm optical trocar (preferable balloon trocars) 5 or 10 mm 30° laparoscope 3 or 5 mm Maryland dissector 3 or 5 mm atraumatic grasper 3 or 5 mm needle holder 3 or 5 mm Metzenbaum scissors 3 or 5 mm hook monopolar cautery (grounding pad) Non-absorbable 4-0 polypropylene suture (to suspend the pyelon) • 5-0 or 4-0 braided polyglactin sutures (for the anastomosis) • Double-J ureteric catheter

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_31

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• Peel-away introducer set (for placement of ureteric catheter) • Blue dye (for bladder filling)

31.4.2 Positioning Half-supine (45°) positioning on a vacuum mattress with the patient placed at the contralateral rim of the table. Thus, the ipsilateral side is elevated and by further tilting the table to the contralateral side, an excellent intraoperative exposure is achieved. The patient should be secured by tape to the bed to allow safe tilting of the table to the contralateral side during the procedure. The contralateral arm is tucked to the side and Fig. 31.1  Positioning of patient, surgeons and monitors

the ipsilateral one in 90° above the head without stretching of the brachial plexus. The surgeon stands on the contralateral side while the first assistant (camera holder) sits next to him. The scrub nurse stands on the ipsilateral side. The monitor is placed ipsilaterally. The abdomen and flank is prepped and draped from the nipples to the symphysis (Fig. 31.1).

31.4.3 Trocar Placement A 5 or 10 mm optical trocar is introduced through the umbilicus and capnoperitoneum is established (pressure 8–10 mmHg, flow 4 l/min—depending on the patient age). The 30° scope is introduced and further trocars are placed

Legend

Patient

Monitor Surgeon Assistant Scrub nurse

Instrument table

32  Laparoscopic Pyeloplasty

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Fig. 31.2  Trocars in place

Legend Working trocar Endoscope trocar

under direct vision. One 3 or 5 mm trocar in the epigastrium and one 3 or 5 mm trocar in the lower ipsilateral quadrant, avoiding the epigastric vessels. Thus, a triangular working access to the ipsilateral kidney is achieved (Fig. 31.2).

31.4.4 Operative Milestones After placement of the trocars, the table is maximally tilted to the contralateral side to allow the small intestine moving away from the operating field. The ascending or descending colon is pulled medially by an atraumatic grasper and the parietal peritoneum is incised laterally with the monopolar hook cautery. After full mobilization of the colon (Milestone 31.1), the Gerota fascia with the underlying kidney is identified. In most cases the dilated pyelon is already seen through the fascia. Then, the pyelon is grasped and after further mobilization suspended to the abdominal wall with 1–2 percutaneous 4.0 polypropylene sutures on a large needle. The ureteropelvic junction is dissected (Milestone 31.2) and a possible aberrant lower-pole vessel is identified. It is important to dissect the proximal ureter only as far as necessary in order to respect the blood supply. In cases with an aberrant vessel, the ureter has to be completely mobilized behind the vessel. Then the ureter is grasped at the site of the stenosis and twisted medially,

Milestone 31.1  Mobilization of the colon (Video 31.1 Lap pyeloplasty). (▸ https://doi.org/10.1007/000-2vt)

Milestone 31.2  Dissection of the pyeloureteral junction

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Milestone 31.3  Spatulation of the ureter

Milestone 31.4  Resection of the pyelon

Milestone 31.5  Suturing the back wall of the anastomosis

allowing a half-diameter incision laterodorsal with the hook scissors. Now, one branch of the Metzenbaum scissors is inserted in the ureteric lumen and sufficient spatulation is performed (Milestone 31.3). After incision of the pyelon, a sucker is inserted to evacuate the pyelon. The incision is circumferentially completed with partial resection of the dilated pyelon (Milestone 31.4). Careful atten-

G. Goetz et al.

Milestone 31.6  Placement of ureteric catheter

Milestone 31.7  Completion of the anastomosis

tion has to be paid to preserve the renal calices. In cases with an aberrant lower-pole vessel, the resected pyelon and proximal ureter are retracted under the vessels und placed anteriorly for the anastomosis. After ureteric transposition the posterior wall of the anastomosis is sutured with interrupted 5-0 or 4-0 braided polyglactin sutures at the lowest point of the pyelon (Milestone 31.5). The knots are tied extraluminally. A double-J ureteric catheter is inserted in an antegrade fashion over a guide wire, which is brought in via an introducer set and a stab incision in the upper quadrant (Milestone 31.6). Correct positioning of the distal catheter tip in the bladder is confirmed by backflow of blue dye, which is instilled intravesically via the preoperatively inserted Foley. The proximal tip is placed into the pyelon, which is flushed with saline several times using the laparoscopic suction-irrigator in order to avoid any residual blood clots, which may obstruct the ureteric catheter postoperatively. The anterior wall of the anastomosis is completed by either interrupted or running sutures (Milestone 31.7). Finally, the capnoperitoneum is released, the trocars are removed and the insertion sites are closed.

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31.5 Postoperative Care

31.7 Pitfalls & Ways to Avoid

The nasogastric tube and the Foley catheter are removed in the operating room. Oral feeds can be started on the same day. The patient is put on prophylactic antibiotics and oral analgetics. An immediate return to normal activities without restrictions is allowed. The correct position of the double-J catheter is confirmed by ultrasound. Discharge can take place upon complete mobilization. Postoperative complications comprise urinoma, catheter-related issues like dislocation or temporary obstruction and recurrent stenosis.

1. To avoid recurrent stenosis it is important to capture mucosa (especially on the ureteric site) when suturing. If there remains any uncertainty, the stitch should be repeated. 2. A moderate dilated pyelon may be difficult to identify and dissect. Additional intravenous administration of fluids and furosemide may help dissection of the pyelon. 3. In some cases, the intraoperative vision is hindered by the colon. Complete mobilization of the colon up to the colonic flexure can facilitate colonic mobilization. 4. Placement of a double-J catheter can sometime cause difficulties. Alternatively, a transrenal/transcutaneous stent can be inserted from the inside-out by transrenal puncture using a specially constructed spear.

31.6 Pearls/Tips & Tricks 1. In cases of massively dilated small intestines, which can easily hinder intraoperative sight in small infants, repeated relaxation by anesthesia can improve vision. 2. In cases of dilated large intestine despite application of a preoperative enema, single puncture with a small needle through the abdomen is a safe and sufficient mean to evacuate the trapped air. 3. In order to define an appropriate spatulation of the ureter in small infants, the closed Metzenbaum scissors is inserted intraluminally to show the ureteric diameter. 4. Starting the anastomosis at the lowest point of the pyelon prevents any windsock effect or postoperative kinking, which may require redo pyeloplasty. 5. Vigorous flushing of the opened pyelon with normal saline before completing the anastomosis may avoid any postoperative catheter obstruction due to blood clots. 6. Attention should be paid regarding the adequate size of the ureteric double-J. Too thin catheters may tend to dislocate whereas a catheter of large diameter may cause some degree of anastomotic tension with possible hypoperfusion of the ureteric wall. Also, the correct length should be chosen according to the size of the patient. 7. The stenotic part of the ureter with adherent resected pyelon serves as a useful handle while manipulating and suturing the spatulated ureter. The final tissue resection may be completed at the end. 8. Completing the anastomosis in a running fashion saves operating time. A barbed suture may be helpful.

References 1. Mei H, Pu J, Yang C, Zhang H, Zheng L, Tong Q.  Laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children: a systematic review and meta-analysis. J Endourol. 2011 May;25(5):727–36. 2. Dingemann J, Ure BM. Systematic review of level 1 evidence for laparoscopic pediatric surgery: do our procedures comply with the requirements of evidence-based medicine? Eur J Pediatr Surg. 2013 Dec;23(6):474–9. 3. Goetz G, Klora M, Zeidler J, Eberhard S, Bassler S, Mayer S, Gosemann JH, Lacher M. Surgery for pediatric ureteropelvic junction obstruction-comparison of outcomes in relation to surgical technique and operating discipline in Germany. Eur J Pediatr Surg. 2019 Feb;29(1):33–8. 4. Piaggio LA, Corbetta JP, Weller S, Dingevan RA, Duran V, Ruiz J, Comparative LJC.  Prospective, case-control study of open versus laparoscopic pyeloplasty in children with ureteropelvic junction obstruction: long-term results. Front Pediatr. 2017 Feb 1;5:10. 5. Cundy TP, Harling L, Hughes-Hallett A, Mayer EK, Najmaldin AS, Athanasiou T, Yang GZ, Darzi A. Meta-analysis of robot-assisted vs conventional laparoscopic and open pyeloplasty in children. BJU Int. 2014 Oct;114(4):582–94. 6. Chan YY, Durbin-Johnson B, Sturm RM, Kurzrock EA. Outcomes after pediatric open, laparoscopic, and robotic pyeloplasty at academic institutions. J Pediatr Urol. 2017 Feb;13(1):49.e1–6. 7. Abdel-Karim AM, Fahmy A, Moussa A, Rashad H, Elbadry M, Badawy H, Hammady A.  Laparoscopic pyeloplasty versus open pyeloplasty for recurrent ureteropelvic junction obstruction in children. J Pediatr Urol. 2016 Dec;12(6):401.e1–6.

Laparoscopic Transperitoneal Simple Nephrectomy

32

Illya Martynov, Christoph Zoeller, Joachim F. Kuebler, and Martin Lacher

32.1 I ndications for Laparoscopic Simple Nephrectomy The indications for laparoscopic simple nephrectomy (LSN) include benign renal diseases with irreversible kidney damage such as multicystic dysplastic kidneys, diseased kidneys causing renovascular hypertension, end-stage ureteropelvic junction obstruction, and nonfunctioning or chronically infected kidneys due to reflux nephropathy [1]. LSN has been proven to be safe, effective and associated with a low complication rate while offering better cosmetic results and reduced postoperative morbidity [2–4].

32.2 Preoperative Workup and Considerations Preoperative evaluation consists of laboratory studies including complete blood cell count, electrolyte assessment, blood urea nitrogen, and creatinine. Confirmatory imaging using ultrasound and magnetic resonance tomography are frequently required. Mercaptoacetyltriglycine (MAG3) or dimercaptosuccinic acid (DMSA) renal scan is needed to assess the function of the affected and non-affected kidneys or kidney moiety. Preoperative enema for colonic decompression and a Foley catheter to empty the bladder facilitate the intraoperative working space. Also, at the beginning of the operation a retrograde insertion of a ureteral catheter into the moiety which needs to remain via cystoscopy may help Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_32. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. I. Martynov (*) · C. Zoeller · J. F. Kuebler · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]

to prevent resection of the healthy ureter. Administration of perioperative antibiotics is warranted.

32.3 Anesthetic Considerations LSN is typically performed under general endotracheal anesthesia. A nasogastric tube should be in place for the duration of the procedure and removed afterward. Two peripheral intravenous catheters are sufficient without any need for central venous line. Especially in infants prevention of hypothermia has to be addressed.

32.4 Operative Technique 32.4.1 Equipment • 5 or 10  mm optical trocar (preferable balloon-tipped trocars) • 5 or 10 mm 30° laparoscope • 3 or 5 mm maryland dissector • 3 or 5 mm atraumatic grasper • 3 or 5 mm needle holder • 3 or 5 mm metzenbaum scissors • 3 or 5 mm hook monopolar cautery (grounding pad) • Non-absorbable 4-0 polypropylene suture • 5-0 or 4-0 braided polyglactin sutures • 5-mm sealing device

32.4.2 Positioning The patient is placed in a half-supine (45°) position on a vacuum mattress with the side of interest up (for left-sided procedures, the patient lies on the right side). The chest and pelvis of the patient are secured by wide tape allowing safe tilting of the table during the procedure. The contralateral

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_32

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180 Fig. 32.1  Positioning of patient, surgeons and monitors

I. Martynov et al.

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

arm is tucked to the side and the ipsilateral one in 90° above the head. An axillary roll should be used to prevent brachial plexus injury. The surgeon stands on the contralateral side while the first assistant sits next to him. The scrub nurse stands on the ipsilateral side. The monitor is placed ipsilaterally. The abdomen and flank is prepped and draped from the nipples to the symphysis (Fig. 32.1).

32.4.3 Trocar Placement A 5 or 10 mm optical trocar is introduced through the umbilicus and capnoperitoneum is established (pressure 8–10 mmHg, flow 4 l/min—depending on the patient age). A 30° scope is introduced and further trocars (3 or 5 mm) are placed under direct vision in the epigastrium and the lower ipsilateral quadrant. Thus, a three-trocar configuration is achieved (Fig. 32.2).

32.4.4 Operative Milestones After placement of the 5 mm trocar at the umbilicus as for a 5  mm-scope, the abdomen is then insufflated with carbon dioxide. Under direct vision, two or three (depending on the operated side) additional working ports (3.5 and/or 5  mm) are inserted pararectally cranial and caudal to the umbilicus in order to gain sufficient triangulation. To obtain maximum exposure of the right or left upper quadrant, the patient is placed in a semilateral position with the ipsilateral side ele-

Legend

Working trocar Endoscope trocar

Fig. 32.2  Trocars in place

vated by tilting the table. This position helps gravidity-­ induced retraction of the colon medially, unless a transmesenteric approach is preferred. The small intestine is then also moved away from the operating field. The ascending or descending colon is pulled medially using an atraumatic grasper to expose the ureter and the anterior renal surface. The parietal peritoneum is incised laterally using electrocautery (Milestone 32.1). Care should be taken to remain lateral enough to avoid damage to the colonic mesentery. After full mobilization of the colon, the Gerota fascia with the underlying kidney is visualized. The ureteropelavic junction and the proximal ureter are dissected until the renal

32  Laparoscopic Transperitoneal Simple Nephrectomy

hilum is identified. The distal ureter is found at the medial aspect of the psoas, which serves as s frame of reference in the localization of it. The renal hilum is identified by placing traction on the proximal ureter. Gerota’s fascia is incised accessing the renal vein and artery. Safe vascular isolation is the primary goal of this operation step. The adrenal, descending lumbar, and gonadal veins are clearly dissected and thereafter ligated using two clips of their proximal sides and one clip on the distal side. The renal artery can be identified posterior to the vein. Maryland or right-angle dissector is used to separate the renal vein and artery from the surrounding tissues (Milestone 32.2). First, ligate the artery using at least two hemostatic clips on the proximal end of it. The kidney becomes uniformly ischemic and the renal vein decompressed and flat. Endovascular GIA is used to ligate the renal vein (Milestone

181

32.3). The ipsilateral adrenal gland and the supplying adrenal vessels are spared except in cases in which the gland is densely adhered to the upper pole of the kidney or has to be removed (e.g. malignant diseases). Next, dissect the superior pole of the kidney from its peritoneal attachments (Milestone 32.4) by placing gentle superior traction on the liver (right-sided procedure) or carefully retraction of the spleen (left-sided procedure). After ligating of the renal vessels and freeing of the upper pol of the kidney, superior incision through the Gerota´s fascia is performed enabling the renal capsule visualization. When the dissection is complete and Gerota´s fascia is removed from the kidney, double clip the proximal ureter and make an incision between the clips (Milestone 32.5). The kidney is now entirely freed from any attachments and prepared for removal.

Milestone 32.1  The parietal peritoneum is incised laterally using electrocautery and the ascending or descending colon is pulled medially using an atraumatic grasper to expose the ureter and the anterior renal surface (Video 32.1 Simple nephrectomy). (▸ https://doi.org/10.1007/000-2vv) Milestone 32.3  Endovascular GIA is used to ligate the renal vein after clipping of renal artery

Milestone 32.2  Separation of the renal vein and artery from the surrounding tissues using Maryland or right-angle dissector

Milestone 32.4  Dissection of the superior pole of the kidney from its peritoneal attachments

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32.5 Postoperative Care At the end of the procedure the nasogastric tube and the Foley catheter are removed in the operating room. Oral feeds can be started on the same day. The patient is put on oral analgetics. An immediate return to normal activities without restrictions is allowed.

32.6 Pearls/Tips & Tricks

Milestone 32.5  Clipping and subsequent Incision of the proximal ureter

1. Hemostasis is critical at this point in the procedure. Options include direct suturing of vessels, hemostatic agents, and bolstering devices. 2. In cases of massively dilated small intestines, which can easily hinder intraoperative sight in small infants, repeated relaxation by anesthesia can improve vision. 3. In cases of a dilated colon despite preoperative enema, single puncture with a small needle through the abdomen is a safe and effective way to evacuate intraluminal air.

32.7 Pitfalls & Ways to Avoid 1. In some cases, the intraoperative vision is hindered by the colon. Complete mobilization of the colon up to the colonic flexure can facilitate its relocation medially. 2. Smoke formation by using the monopolar hook for colon mobilization and dissection of the pyelon can be relieved by intermittent evacuation of the capnoperitoneum through a short line, which is connected to one of the trocars. Milestone 32.6  Removal of the kidney without specimen retrieval bag

References

The kidney can be removed either intact or morcellated. Carry out morcellation by placing a sturdy impermeable bag through the umbilical port. Place the kidney inside the bag and morcellate with either the electronic morcellator or manual ringed forceps. Remove the bag containing the morcellated contents through the umbilical port incision. Alternatively, place the specimen in a specimen retrieval bag via an extension of the umbilical port incision or through a Pfannenstiel incision (Milestone 32.6).

1. Jesch NK, Metzelder ML, Kuebler JF, et  al. Laparoscopic transperitoneal nephrectomy is feasible in the first year of life and is not affected by kidney size. J Urol. 2006;176:1177–9. 2. Denes FT, Tavares A, Monteiro ED, et al. Laparoscopic renal surgery in infants and children: is it a feasible and safe procedure for all pediatric age groups? Int Braz J Urol. 2008;34:739–46. discussion 746-738 3. Castillo OA, Foneron-Villarroel A, Lopez-Fontana G, et  al. Laparoscopic nephrectomy in children. Actas Urol Esp. 2011;35:195–9. 4. Szavay PO. Applications of laparoscopic transperitoneal surgery of the pediatric urinary tract. Front Pediatr. 2019;7:29.

Laparoscopic Transperitoneal Heminephrectomy

33

Illya Martynov, Christoph Zoeller, Joachim F. Kuebler, and Martin Lacher

33.1 Indications for Laparoscopic Heminephrectomy Laparoscopic heminephrectomy (LHN) may be indicated in children with ectopic ureter or vesico-ureteral reflux related to the poorly or non-functioning moiety of a duplex renal system [1]. The aim of surgical management is to prevent urinary tract infections, to protect the normal ipsilateral moiety and contralateral kidney or to preserve urinary continence. Several studies comparing minimally invasive and open approaches for LHN suggest that utilization of laparoscopy is associated with decreased postoperative analgesia requirements, shorter hospital stay, less blood loss, better cosmetic results, and reduced postoperative morbidity with equivalent success and complication rates [2–4].

33.2 Preoperative Workup and Considerations Preoperative evaluation consists of laboratory studies including complete blood cell count, electrolytes, blood urea nitrogen, and creatinine. Confirmatory imaging using ultrasound and magnetic resonance tomography are frequently required. Mercaptoacetyltriglycine (MAG3) or dimercaptosuccinic acid (DMSA) renal scan is needed to assess the function of the affected and non-affected kidneys or kidney moiety. A preoperative enema for colonic decompression and a Foley catheter to empty the bladder increase the intraoperative Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_33. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. I. Martynov (*) · C. Zoeller · J. F. Kuebler · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]

working space. Also, some authors cystoscopically insert a ureteral catheter into the remaining moiety at the beginning of the operation to better identify the healthy ureter during the operation.

33.3 Anesthetic Considerations LHN is typically performed under general endotracheal anesthesia. A nasogastric tube should be placed for the duration of the procedure and removed afterwards. Two peripheral intravenous catheters are sufficient without any need for central venous line.

33.4 Operative Technique 33.4.1 Equipment • • • • • • • • • •

5 or 10 mm optical trocar (preferable balloon trocars) 5 or 10 mm 30° laparoscope 3 or 5 mm Maryland dissector 3 or 5 mm atraumatic grasper 3 or 5 mm needle holder 3 or 5 mm Metzenbaum scissors 3 or 5 mm hook monopolar cautery (grounding pad) Non-absorbable 4-0 polypropylene suture 5-0 or 4-0 braided polyglactin sutures 5-mm advanced bipolar sealing device

33.4.2 Positioning The patient is placed in a half-supine (45°) position on a vacuum mattress with the side of interest up (for left-sided procedures, the patient lies on the right side). Chest and pelvis of the patient are secured by wide tape allowing safe ­tilting of the table during the procedure. The contralateral

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_33

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184 Fig. 33.1  Positioning of patient, surgeons and monitors

I. Martynov et al.

Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

arm is tucked to the side and the ipsilateral one in 90° above the head. An axillary roll should be used to prevent brachial plexus injury. The surgeon works from the contralateral side while the first assistant sits next to him. The scrub nurse stands on the ipsilateral side. The monitor is placed ipsilaterally. Abdomen and flank are prepped and draped from the nipples to the symphysis (Fig. 33.1).

33.4.3 Trocar Placement A 5 or 10 mm optical trocar is introduced through the umbilicus and capnoperitoneum is established (pressure 8–10 mmHg, flow 4 l/min – depending on the patient age). A 30° laparoscope and further trocars (3 or 5 mm) are inserted under direct vision in the epigastrium and the lower ipsilateral quadrant. Thus, a triangular configuration is achieved (Fig. 33.2).

33.4.4 Operative Milestones (Upper Pole LHN) After placement of the trocars, the abdomen is insufflated with carbon dioxide using a maximum pressure of 8–10  mmHg (pressures from 8–14  mmHg depending on patient age and surgeon's preference) and a maximum flow of 5  L/min. A 10-mm, 30°, 45-cm scope is introduced through the umbilical port. Under direct vision, two or three (depending on the operated side) additional working ports (3.5 and 5 mm) are inserted pararectally cranial and caudal to

Legend

Working trocar Endoscope trocar

Fig. 33.2  Trocars in place

the umbilicus in order to gain a 60° manipulation angle. To obtain maximum exposure of the right or left upper quadrant, the patient is placed in a semilateral position with the ipsilateral side elevated by tilting the table. This position helps gravidity-induced retraction of the colon medially. The small intestine is then also moved away from the operating field. The ascending or descending colon is pulled medially using an atraumatic grasper to expose the ureter and the anterior renal surface. The parietal peritoneum is incised laterally using electrocautery (Milestone 33.1). Care is taken to remain lateral enough to avoid damage to the colonic mesentery.

33  Laparoscopic Transperitoneal Heminephrectomy

After full mobilization of the colon, the dissection of the dilated (upper pole) ureter starts distally and proceeds in proximal direction until the renal pedicle is reached and the anatomy (renal hilum with vessels, identification of both ureters) is clear (Milestone 33.2). Once this is accomplished, the ureter is followed down into the pelvis and divided (Milestone 33.3). In case of a non-refluxing ureter this may be done at the level of the iliac

Milestone 33.1  The parietal peritoneum is incised laterally using electrocautery and the ascending or descending colon is pulled medially using an atraumatic grasper to expose the ureter and the anterior renal surface (Video 33.1 Heminephrectomy). (▸ https://doi.org/10.1007/000-2vw)

Milestone 33.2  The dissection of the dilated (upper pole) ureter starts distally and proceeds in proximal direction until the renal pedicle is reached and the anatomy (renal hilum with vessels, identification of both ureters) is clear Milestone 33.4 (a, b) For upper pole LHN the ureter originating from the upper renal pelvis is dissected dorsally to the vessels supplying the lower pole and then passed underneath the renal pedicle to assist with further traction (Milestone 33.4)

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vessels, in children with refluxing moieties the ureter is followed down further to the bladder and only a little ureteral stump should be left to prevent urinary tract infections. For division of the ureter a stich-ligation using polyglactin 4/0, clips or the ultrasound scalpel can be used. Next, the vessels supplying upper pol of the kidney are defined and divided. After this the upper pol of the kidney becomes uniformly ischemic and the line of demarcation can be seen. This line is usually small; therefore a sealing device for ligation of the vessels is sufficient. Uppermost care must be taken to avoid collateral vascular damage to the remaining moiety. Also, the adrenal gland, descending lumbar and gonadal veins should be preserved. For upper pole LHN the ureter originating from the upper renal pelvis is dissected dorsally to the vessels supplying the lower pole and then passed underneath the renal pedicle to assist with further traction (Milestone 33.4 a, b). Respecting the line of demarcation, the upper pole ureter is now used as a handle and the renal parenchyma is divided using a sealing device (Milestone 33.5). Once the separation of two renal moieties and hemostasis are completed, the lower renal pelvis has to be checked for accidental injury. Any hole in the lower pole renal pelvis must be closed with interrupted stiches to prevent urine leakage. Finally, the resected specimen is removed through the umbilical port incision. The capnoperitoneum is released,

Milestone 33.3  The ureter is followed down into the pelvis and divided

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2. In cases of massively dilated small intestines, which can easily hinder intraoperative sight in small infants, repeated relaxation by anesthesia can improve vision. 3. In cases of a dilated colon despite preoperative enema, single puncture with a small needle through the abdomen is a safe and effective way to evacuate intraluminal air.

33.7 Pitfalls & Ways to Avoid

Milestone 33.5  Respecting the line of demarcation, the upper pole ureter is now used as a handle and the renal parenchyma is divided using a sealing device

the trocars are removed and the insertion sites are closed. Drains or urinary catheters are not routinely placed.

33.5 Postoperative Care At the end of the procedure the nasogastric tube and the Foley catheter are removed in the operating room. Oral feeds can be started on the same day. The patient is put on oral analgesics. An immediate return to normal activities without restrictions is allowed.

33.6 Pearls/Tips & Tricks 1. Hemostasis is critical at this point of the procedure. Options include direct suturing of vessels, hemostatic agents, and bolstering devices.

1. In some cases, the intraoperative vision is hindered by the colon. Complete mobilization of the colon up to the colonic flexure can facilitate its relocation medially. 2. Smoke formation by using the monopolar hook for colon mobilization and dissection of the pyelon can be relieved by intermittent evacuation of the capnoperitoneum through a short line, which is connected to one of the trocars.

References 1. Dingemann C, Petersen C, Kuebler JF, Ure BM, Lacher M. Laparoscopic transperitoneal heminephrectomy for duplex kidney in infants and children: a comparative study. J Laparoendosc Adv Surg Tech A. 2013;23(10):889–93. 2. Neheman A, Kord E, Strine AC, et  al. Pediatric partial nephrectomy for upper urinary tract duplication anomalies: a comparison between different surgical approaches and techniques. Urology. 2018;125:196–201. 3. Golebiewski A, Losin M, Murawski M, et  al. Laparoscopic versus open upper pole heminephroureterectomy for the treatment of duplex kidneys in children. J Laparoendosc Adv Surg Tech A. 2013;23:942–5. 4. Romao RL, Weber B, Gerstle JT, et al. Comparison between laparoscopic and open radical nephrectomy for the treatment of primary renal tumors in children: single-center experience over a 5-year period. J Pediatr Urol. 2014;10:488–94.

Extravesical Ureteral Reimplantation (Lich-Gregoir)

34

Ciro Esposito, Mariapina Cerulo, Fulvia Del Conte, Vincenzo Coppola, and Maria Escolino

34.1 Indications for Robot-assisted Approach to Vesico-ureteral Reflux Indications for intervention include breakthrough urinary tract infections (UTIs), progressive renal scarring and persistent vesico-ureteral reflux (VUR) despite watchful waiting with parental request for surgical intervention. The robot-­ assisted approach is indicated in case of high-grade (III-V) primary VUR [1]. Additionally, challenging cases of VUR associated with “complex” distal ureteral anatomy including previous anti-reflux surgery, duplication anomalies, periureteral diverticula, and megaureters requiring ureteral tapering and bilateral pathology are good candidates for robot-assisted approach as well [2].

34.2 Preoperative Workup and Considerations Pre-operative work-up includes laboratory blood parameters (creatinine, urea) and urinalysis, renal ultrasonography, voiding cystourethrogram (VCUG) for VUR grading and evaluation of urethra, and renal scan for renal function assessment in each patient.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_34. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. C. Esposito (*) · M. Cerulo · F. Del Conte · V. Coppola · M. Escolino Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy e-mail: [email protected]

34.3 Anesthetic Considerations The procedure is performed under general anesthesia with endotracheal intubation. Patient comorbidities do not play a major role in the decision for robotic repair; however, patients with severe deficits in pulmonary reserve need to be carefully evaluated preoperatively by an anesthesiologist to determine if abdominal insufflation may impair ventilation [3]. The indications for robot-assisted repair should be restricted to patients older than 2 years of age and of a body weight greater than 15 kg. Since small children are particularly sensitive to the effects of pneumoperitoneum, this type of surgery should be accomplished in a timely fashion, limiting the insufflation time and keeping the insufflation pressure as low as possible. Additionally, a correct set-up of the operating room, including positioning of the robot, robotic console, scrub table and anesthesia machines, is crucial to guarantee an optimal collaboration and communication among all members of the robotic team (main surgeon, assistant surgeon, anesthesiologists, nurses) during surgery [4].

34.4 Operative Technique 34.4.1 Equipment • 8-mm robotic ports • 5-mm assistant laparoscopic port • 5-mm laparoscopic instruments (scissors, grasper, needle driver) to be used through the 5-mm assistant port • 8-mm robotic needle driver • 8-mm robotic monopolar curved scissors • 8-mm robotic Cadiere grasper • 8-mm robotic Maryland bipolar forceps • Umbilical tape (or ureteral retraction) • 2/0 polyglactin suture with 60-mm straight needle (for bladder suspension) • 4-0 braided polyglactin sutures (for extravesical reimplantation)

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34.4.2 Positioning The patient is placed in supine position with the legs apart, and the operating table is placed in 10 degree Trendelenburg position to encourage the bowel to fall out of the pelvis. For bilateral cases, the robot is situated at the patient’s feet in the midline; however, for unilateral repairs the robot is placed at the ipsilateral foot end (Fig. 34.1). An age-appropriate bladder catheter is inserted preoperatively, to be used later for bladder hydrodistention intra-operatively during the detrusorotomy and for postoperative urine drainage.

34.4.3 Trocar Placement For the REVUR procedure, four trocars are placed: one 8-mm camera port is inserted in the umbilicus for the 30° robotic optic and the other two 8-mm robotic ports are inserted at 7–9  cm apart from the camera port along the midclavicular line bilaterally. Finally, the fourth 5-mm assistant port is placed in the ipsilateral hypochondriac region (Fig. 34.2). In children less than 20 kg, the working ports are preferably placed at the level of the umbilicus to ensure a good distance to the target site. The robot is then docked.

34.4.4 Operative Milestones

34.5 Postoperative Care The bladder catheter is left in place for 24–48 h postoperatively. Full oral feeding is restarted on the same day as tolerated. Pain control is obtained with oral analgesic medication. Follow-up is performed with renal ultrasound at 1 month and thereafter at 6 and 12 months postoperatively and voiding cystourethrogram (VCUG) is obtained at 6 months postoperatively to assess the VUR resolution.

34.6 Pearls/Tips & Tricks

The colon is mobilized along the line of Toldt and the peritoneum covering the ureter is incised and the ureter is mobilized to the level of the vas deferens or uterine artery. An umbilical tape is placed around the ureter to avoid injury to adventitial vasculature from excessive direct manipulation. Ureteral isolation proceeds distally toward the uretero-­ vesical junction (UVJ) (Milestone 34.1). A peritoneal window is then created distal to the vas deferens or uterine ligament and the ureter is then decrossed, preserving these structures (Milestone 34.2). The bladder is filled with saline solution in order to avoid the risk of perforation at the time of detrusorotomy. A transabdominal stay suture (2/0 polyglactin) is placed in order to elevate the bladder to aid in the detrusorotomy. The stitch is placed in midline for bilateral cases whereas it is placed laterally for Fig. 34.1  Positioning of patient (a), trocars and the telemanipulator (Robot) (b)

unilateral procedures. Using the monopolar scissors, a 2.5–3  cm detrusor incision is made at the ipsilateral posterosuperior part of the bladder till the mucosa is seen pouting out (Milestone 34.3). The detrusor muscle is then separated from the mucosa laterally, preparing the muscular flaps used to create the detrusor tunnel. The optimal length of the tunnel should be about four times the size of the ureter (Paquin law). The ureter is placed in the newly created tunnel and the detrusor muscle is reapproximated with three or four interrupted stitches with 4-0 resorbable sutures (Milestone 34.4). After detrusorrhaphy at the apex, precaution is taken not to make the closure tight and, ideally, there should be space to accommodate the tip of the needle holder. The trocars orifices are closed using resorbable sutures. No drain is left at the end of surgery.

a

1. We usually limit the direct manipulation of the ureter by placing a tape around it and grasping the end of the tape in order to obtain a better exposure of the ureter and ease the ureteral dissection. 2. Before detrusorotomy, we prepare the bladder by suspending it with a transabdominal stitch and filling it with saline; in this way, we are able to perform ureteral mobilization and detrusor dissection to as distally as possible until a 5:1 ratio of tunnel length to ureteral diameter according to Paquin’s law can be achieved [5]. 3. Throughout the creation of the detrusor tunnel and the detrusorotomy, we intermittently insulate the bladder through the indwelling bladder catheter with a second insulation unit to ensure appropriate position of the ureter. b Legend 8mm Working trocar 8mm Endoscope trocar 5mm Accessory trocar Robot

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Milestone 34.3  The detrusorotomy is performed to create the anti-­ reflux tunnel

Fig. 34.2  Positioning of the trocars

Milestone 34.4  The detrusor flaps are closed over the ureter with 3–4 interrupted stitches to complete extra-vesical reimplantation

34.7 Pitfalls & Ways to Avoid Milestone 34.1  The ureter is mobilized towards the vesico-ureteral junction (VUJ) (Video 34.1 Esposito video REVUR technique). (▸ https://doi.org/10.1007/000-2vx)

Milestone 34.2  The ureter is decrossed from the uterine ligament through a peritoneal window

1. One of the most frequent complications following extravesical ureteral reimplantation is postoperative urinary retention [6]. This complication has been mainly attributed to iatrogenic injury of the pelvic neurovascular plexus during ureteral dissection [7, 8]. We suggest to isolate the ureter, while keeping the vessels and adventitia intact, to minimize the use of electrocautery during the dissection of the region around the ureterovesical junction and to create a detrusor tunnel in the posterior wall using monopolar scissors. 2. Extensive use of electrocautery should also be avoided during the dissection of the ureter in order to reduce the risk of perioperative ureteral leakage.

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References 1. Esposito C, Masieri L, Steyaert H, Escolino M, Cerchione R, La Manna A, et al. Robot-assisted extravesical ureteral reimplantation (revur) for unilateral vesico-ureteral reflux in children: results of a multicentric international survey. World J Urol. 2018;36(3):481–8. 2. Arlen AM, Broderick KM, Travers C, Smith EA, Elmore JM, Kirsch AJ. Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population. J Pediatr Urol. 2016;12:169. e1–6. 3. Lendvay T. Robotic-assisted laparoscopic management of vesicoureteral reflux. Ther Adv Urol. 2008; https://doi.org/10.1155/2008/732942. 4. Joseph JP, Gundeti MS.  Robot-assisted anterior wall extravesical ureteral reimplantation. J Pediatr Urol. 2015;11:45–6.

C. Esposito et al. 5. Dangle PP, Shah A, Gundeti MS.  Robot-assisted laparoscopic ureteric reimplantation: extravesical technique. BJU Int. 2014;114:630–2. 6. Esposito C, Varlet F, Riquelme MA, Fourcade L, Valla JS, Ballouhey Q, Scalabre A, Escolino M.  Postoperative bladder dysfunction and outcomes after minimally invasive extravesical ureteric reimplantation in children using a laparoscopic and a robot-assisted approach: results of a multicentre international survey. BJU Int. 2019;124(5):820–7. 7. Leissner J, Allhoff EP, Wolff W, et al. The pelvic plexus and antireflux surgery: topographical findings and clinical consequences. J Urol. 2001;165:1652–5. 8. Casale P, Patel RP, Kolon TF.  Nerve sparing robotic extravesical ureteral reimplantation. J Urol. 2008;179:1987–90.

Laparoscopic Varicocelectomy

35

Robin Wachowiak, Illya Martynov, and Martin Lacher

35.1 Indications for Laparoscopic Approach to Varicocelectomy Indications for surgery of varicoceles include symptoms like scrotal pain, testicular volume discrepancy (>20% decrease on the affected side), and abnormal semen analysis [1]. The goal of treatment is to block the reflux in the internal spermatic vein while preserving the internal spermatic artery and vas deferens. Different procedures have been reported including laparoscopy, which has gained popularity in recent years [2, 3]. Laparoscopic techniques include the inguinal ligation of the enlarged testicular vessels (Ivanissevitch operation) or high retroperitoneal mass ligation of all enlarged vessels above the internal inguinal ring (Palomo procedure) [4]. Moreover, modifications such as internal spermatic artery–sparing procedures, lymphatic-sparing techniques, and plication of the spermatic fascia over the enlarged vessels have been described [4].

35.2 Preoperative Workup and Considerations Physical examination is performed in supine and standing positions. Varicocele can be identified as a nontender mass (“bag of worms”) above the testis during palpation. Preoperative ultrasound is mandatory to exclude renal tumors or hydronephrosis as a cause of mechanical compression of the testicular vein. In the OR, a urinary catheter is not routinely inserted. We do not apply perioperative antibiotics. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_35. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. R. Wachowiak (*) · I. Martynov · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]

35.3 Anesthetic Considerations Laparoscopic varicocelectomy is performed under general anesthesia and endotracheal intubation with muscle relaxation. The elective operation is usually performed in an outpatient setting.

35.4 Operative Technique (Palomo Procedure) 35.4.1 Equipment 35.4.1.1 Conventional Technique • 3 or 5 mm and instruments and trocars • 5  mm 30° laparoscope 3- or 5-mm Kelly or Maryland dissector • 3 or 5 mm Metzenbaum scissors • 5 mm clip applier • 3 or 5 mm hook monopolar cautery (grounding pad) 35.4.1.2 S  IPES (Single-incision Pediatric Endosurgical) Technique • A wound retractor • Size 6.5 latex sterile powder-free surgical glove as described previously (see Chapter SIPES Appendectomy) • A 3 or 5  mm 45-cm laparoscope with a 90° angulated light adapter • 5 mm atraumatic grasper • Monopolar hook • Polyglactin suture 2-0

35.4.2 Positioning The patient is placed supine with arms tucked to side. During the procedure it is helpful to bring the patient in Trendelenburg position. The surgeon and the first assistant stand on the right

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Fig. 35.1  Positioning of patient, surgeons and monitors Legend

Patient

Monitor

Surgeon Assistant Scrub nurse

Instrument table

side. The scrub nurse is on the left side. The monitor is placed towards the patient’s feeds (Fig. 35.1).

35.4.3 Trocar Placement Three trocars (generally 2 × 3–5 mm and 1 × 3–5 mm in the umbilicus) are used. The first trocar is inserted through the umbilicus in an open technique for the 5 mm 30-degree telescope. Depending on patients age the pressure/flow of the pneumoperitoneum needs to be kept between 8–10 cm H2O and of 4–6  L/min respectively. For left sided varicocelectomy, a 3–5 mm trocar is placed in the left upper quadrant for the instrument of the left hand. A 5 mm trocar is then inserted in the right lower quadrant for the 5 mm clip applyer (Figs. 35.2 and 35.3).

35.4.3.1 S  ingle Incision Pediatric Endosurgery (SIPES) A 5 mm 45-cm scope is introduced through the before sliced thumb of the glove port into the abdominal cavity and capnoperitoneum is established as described previously [5].

Fig. 35.2  Equipment for varicocelectomy

Legend Working trocar

35.4.4 Operative Milestones The gonadal vessels and internal inguinal ring are identified. The peritoneum is incised with a Metzenbaum scissors or a monopolar hook over a length of 2–3 cm two cm proximal to the internal inguinal ring, taking care not to injure the vessels themselves (Milestone 35.1). The vessels are dissected and mobilized. When a sufficient window is created behind the

Endoscope trocar

Fig. 35.3  Trocar placement for left sided vacicocelectomy

vessels, the vascular bundle is grasped and elevated to position the clips (Milestone 35.2).

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Peritoneal window

Milestone 35.1  After Identification of the spermatic vessels, a peritoneal window of adequate length is incised with a monopolar hook, 2–3 cm two cm proximal to the internal ring (Video 35.1 Laparoscopic varicocelectomy). (▸ https://doi.org/10.1007/000-2vy)

Milestone 35.3  The entire vascular bundle is clipped with non-­ absorbable clips. Two clips are applied distally and proximally, leaving a space of about 1 cm between the clips

Gonadal Vessels

Milestone 35.4 The clipped vessel bundle is divided with Metzenbaum scissors in the space between the proximal and distal clips Milestone 35.2  The spermatic vessels are mobilized and elevated from the underlying psoas muscle

Two non-absorbable polymere ligation clips (or equivalent Metal clips) are placed distal and proximal— leaving a length of 1  cm between the clips (Milestone 35.3). The vessels are then divided between the clips (Milestone 35.4). Alternatively, the vessels may be cauterized. The opened retroperitoneum in this region is examined before closure to make sure that there are no accessory vessels left. Closure of the peritoneum is not necessary. The ports are removed under direct vision.

35.5 Postoperative Care The Patients are discharged on the day of surgery. Non-­ opioid analgetics (e.g Acetaminophen/Paracetamol) are given. Restriction of sports is recommended for 10–14 days. Follow-up is advised after 12-months to exclude recurrence.

35.6 Pearls/Tips & Tricks 1. For incision of the peritoneum a monopolar hook is often better than using cold scissors as it causes less bleeding, which may impair visualization.

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2. If a lymphatic-sparing technique is chosen to prevent hydrocele formation, preoperative injection of methylene blue or isosulfan blue into the space between tunica vaginalis and tunica albuginea of the scrotum offers lymphatic mapping [6]. By staining of lymphatic vessels these structures can then be spared during varicocelectomy. 3. Incision of the peritoneum should be long enough and the window which is created large enough to facilitate safe and gentle mobilization on the vessels. Dissection should be close to the vessels.

35.7 Pitfalls & Ways to Avoid 1. Artery–sparing techniques are associated with a higher relapse rate [7]. 2. Extensive use of cautery or harmonic dissection of the retroperitoneal space can injure the genitofemoral nerve and may result in a sensory deficit of the ipsilateral anterior thigh.

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References 1. Locke JA, Noparast M, Afshar K. Treatment of varicocele in children and adolescents: a systematic review and meta-analysis of randomized controlled trials. J Pediatr Urol. 2017;13(5):437–45. 2. Parrilli A, Roberti A, Escolino M, Esposito C. Surgical approaches for varicocele in pediatric patient. Transl Pediatr. 2016;5(4):227–32. 3. Johnson D, Sandlow J.  Treatment of varicoceles: techniques and outcomes. Fertil Steril. 2017;108(3):378–84. 4. Raheem OA.  Surgical management of adolescent varicocele: systematic review of the world literature. Urol Ann. 2013;5(3):133–9. 5. Martynov I, Lacher M.  Homemade glove port for Single-Incision Pediatric Endosurgery (SIPES) appendectomy—how we do it. European J Pediatr Surg Rep. 2018;6(1):e56–8. 6. Tan HL, Tecson B, Ee MZ, Tantoco J. Lymphatic sparing, laparoscopic varicocelectomy: a new surgical technique. Pediatr Surg Int. 2004;20(10):797–8. 7. Yu W, Rao T, Ruan Y, Yuan R, Cheng F.  Laparoscopic varicocelectomy in adolescents: artery ligation and artery preservation. Urology. 2016;89:150–4.

Laparoscopic Orchidopexy

36

Takafumi Kawano and Satoshi Ieiri

36.1 Indications for a Laparoscopic Approach to Cryptorchidism A testicular descent of a testis located above the scrotum beyond the age of 6 months is very unlikely. In these cases orchidopexy is indicated. Surgery should be performed by the age of 1 year as dysplastic changes in the testis begin at that time with no further improvement of testicular function [1]. The indications for a laparoscopic approach to cryptorchidism include non-palpable abdominal testis, high canalicular testis, polyorchidism, splenogonadal fusions, and transverse testicular ectopia [2, 3].

36.2 Preoperative Workup and Considerations An undescended testis is frequently located along the normal testicular route of descent. The differentiation between palpable or non-palpable and uni- or bilateral cryptorchidism is mandatory in order to guide treatment. Laboratory tests are not always required. Some studies accurately predicted anorchia using hormonal stimulation testing [4]. Imaging modalities, such as ultrasonography, computed tomography, and magnet resonance imaging, have been used. However, intra-­ abdominal testes can be easily missed by radiologic imaging. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_36. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. T. Kawano (*) · S. Ieiri Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan e-mail: [email protected]

If the testis is not palpable in an outpatient setting or under general anesthesia, laparoscopic exploration is recommended. The operative management of an intra-abdominal testis can be challenging due to the presence of short testicular vessels that limit testicular mobility. The surgeon must be familiar with various techniques in order to choose the appropriate procedure.

36.3 Anesthetic Considerations Laparoscopic orchidopexy is typically performed under general anesthesia and endotracheal intubation. Since some patients have associated anomalies these cases should be performed by an experienced pediatric anesthesiologist and the patient should be observed post-surgery for 24  h. Intraoperative hemorrhage is a rare complication. In a routine case, this procedure is typically performed electively in an outpatient setting.

36.4 Operative Technique 36.4.1 Equipment • • • • •

2- or 3- or 5-mm instruments and trocars 3- or 5-mm 30° laparoscope 2- or 3-mm atraumatic grasper 3-mm bipolar scissors 3-mm hook monopolar cautery

36.4.2 Positioning The patient is placed in a supine position. The surgeon stands on the contralateral side of the affected testis; the monitor is placed opposite to the operative surgeon. The assistant stands next to the operative surgeon, the scrub nurse stands on their

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Fig. 36.1  Positioning of patient, surgeons, and monitors

(Affected site : Right)

Patient Working trocar

Monitor

Endoscope trocar

Surgeon Assistant Scrub nurse Instrument table

opposite side (Fig.  36.1). After port placement, the table should be tilted to the side so that the side of the cryptorchidism is elevated, allowing easier visualization of the retroperitoneum.

36.4.3 Trocar Placement The first trocar is placed at the umbilicus. The pneumoperitoneum is established using CO2 insufflation at a pressure of 8  mmHg and a CO2 flow of 4–6  l/min depending on the patient’s age and body weight. Under laparoscope guidance 2 working trocars are inserted on the contralateral side of the abdomen to the affected testis, lateral to the umbilicus on the surgeon’s side of the table (Fig. 36.2).

36.4.4 Operative Milestones After placement of the umbilical trocars and insertion of 2 working trocars, the operation begins with identification of the internal inguinal ring, the vas deferens and gonadal vessels of the affected testis. An open groin exploration is indicated if the vas and vessels are seen at the abdominal internal inguinal ring. Based on the distance of the undescended testis from the internal ring, it is necessary to evaluate the possibility of securing the testicle as, well-placed and tension-free, in the scrotum with a single-stage procedure (Milestone 36.1). If a two-stage Fowler-Stephens orchidopexy is required, high ligation and transection of the gonadal vessels should be performed. The operation is terminated at this stage with a return to the abdomen at a later time point. If a single-stage procedure is considered possible, the retroperitoneum is incised from far lateral to the gonadal vessels. The gonadal vessel should be carefully detached from the retroperitoneum, over the median umbilical ligament (Milestone 36.2). While transection of the gubernaculum testis is performed, injury of the epididymis and the

Legend Working trocar Endoscope trocar

Fig. 36.2  Positioning of the trocars

vas deferens must be prevented as the vas deferens can run in a curved or serpentine configuration. After the transection of the gubernaculum testis is completed, mobilization of testis is less difficult (Milestone 36.3). Similarly, the peritoneum lateral to the vessels is dissected as high as possible lateral to the psoas edge. This should loosen the peritoneum over the gonadal vessels. The dissection is continued to the root of the gonadal vessels. Mobilizing the gonadal vessels and vas deferens should be performed by sharp dissection to prevent injury. Scissors or bipolar scissors, not electrical cautery, is recommended due to the potential of thermal injury. A sub-dartos pouch is created via a scrotal incision. From outside the body, an atraumatic grasper is carefully inserted through the scrotal incision into the abdomen. Care has to be taken not to injure the femoral vessels, inferior epigastric vessels and the bladder (Milestone 36.4). If required, a 3-mm trocar may be inserted from the dartos pouch to prevent injury of the femoral vessels,

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Milestone 36.1  Based on the position of the testis from the internal ring, it is necessary to evaluate the possibility of establishing the testicle as, well-placed and tension-free, in the scrotum with a single-stage procedure (Video 36.1 Laparoscopic orchiopexy). (▸ https://doi.org/10.1007/000-2vz)

Milestone 36.2 The peritoneum is opened from the lateral to the gonadal vessel, and the gonadal vessel should be carefully divided from retroperitoneum, over the median umbilical ligament

internal inguinal ring. Under laparoscopic visualization, the testis is grasped by an atraumatic grasper, paying attention not to grasp the epididymis and/or the vas deferens and verifying that the vessels are not twisted. The testis is pulled down the neo-canal into the scrotum, taking care to limit tension on the vascular pedicle. The testis is fixed by anchoring stiches to its capsule and the dartos pouch. The position of the testis should be examined after desufflation of the abdomen. If the descending length is insufficient to pull the testis into the scrotum, additional dissection or a two-stage procedure should be considered. When performing the Fowler-­ Stephens orchidopexy, the testicular vessels would be clipped and transected, which should provide additional length, as the gonad receives its blood supply from collaterals along the vas deferens. Milestone 36.3  Transection of the gubernaculum testis to facilitate testicular mobilization using a method so as to not injure the epididymis and vas

36.5 Postoperative Care

inferior epigastric vessels and bladder and to retain the pneumoperitoneum. Regarding the descending route, the medial inguinal fossa is recommended as a neo descending route compared to the

After return to normal activities the patient should avoid saddle toys for several weeks. The procedure may be performed in an outpatient setting. The postoperative management is approximately the same as for an inguinal hernia repair.

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Milestone 36.4  From the outside of the body, an atraumatic grasper is inserted carefully through the scrotal incision into the abdomen without injury to the femoral vessels, epigastric vessels, or bladder

36.6 Pearls/Tips & Tricks 1. Evaluation of the testicular position is crucial in order to select the appropriate procedure, especially in high intraabdominal cryptorchidism. 2. If transection of the gonadal vessel is necessary to gain sufficient length, high ligation preserves the collateral vessels between the testicular and deferential arteries. 3. If the testicle is so high that a two-stage Fowler-Stephens procedure is chosen, high ligation of the testicular vessels prior to any peritoneal dissection is completed and orchidopexy should be performed at a later time, within in a few months.

36.7 Pitfalls & Methods to Avoid 1. Injury of the testicular vessels can potentially occur. Provide special attention to traction on the vessels when detaching them from the retroperitoneum and pulling them into the scrotum.

2. Urinary bladder injury can be prevented by inserting a urinary catheter. This complication is suspected when hematuria is present postoperatively [5]. 3. Vascular injury to the femoral vessels can occur when the testis is pulled through the neo-canal. This complication can be avoided by cautious laparoscopic guidance.

References 1. Hutson JM, Thorup J.  Evaluation and management of the infant with cryptorchidism. Curr Opin Pediatr. 2015;27:520–4. 2. Abolyosr A.  Laparoscopic versus open orchidopexy in the management of abdominal testis: a descriptive study. Int J Urol. 2006;13:1421–4. 3. Powell C, McIntosh J, Murphy JP, Gatti J.  Laparoscopic orchidopexy for intra-abdominal testes-a single institution review. J Laparoendosc Adv Surg Tech A. 2013;23:481–3. 4. Shepard CL, Kraft KH. The nonpalpable testis: a narrative review. J Urol. 2017;198:1410–7. 5. Hsieh MH, Bayne A, Cisek LJ, Jones EA, Roth DR. Bladder injuries during laparoscopic orchidopexy: incidence and lessons learned. J Urol. 2009;182:280–4; discussion 284–5.

Laparoscopic Management of Intraabdominal Testis (Shehata Technique)

37

Sameh Shehata

37.1 Indications for Laparoscopic Approach to Intra-abdominal Testis (Shehata Technique) The indications include all cases of Intra-abdominal testis (IAT) confirmed by laparoscopy, the majority of IAT lie within 3 cm from the deep ring and should be amenable to the Shehata technique. The exceptions are the two extremes; the testis which can reach the contralateral deep inguinal ring without any tension (which will be amenable to one stage lap assisted orchiopexy) this is around 10% of all IAT, the other is the exceptionally high IAT (more than 3  cm above the deep ring) or subrenal testis which will require two stage Fowler Stephens approach (around 5–10% of all cases of IAT) (Shehata and Shalaby).

37.2 Preoperative Workup and Considerations The clinical diagnosis is based on failure to palpate the testis in the scrotum or in possible sites of ectopia, this needs to be confirmed under anesthesia. Imaging studies are generally unreliable and are not needed for the true abdominal testis, sonography can used for the undescended testis within the inguinal canal especially in the obese and uncooperative child. It helpful to have empty bladder by urination or Credé’s maneuver just before surgery and an empty colon and rectum by using Bisacodyl suppositories 12 and six hours before surgery.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_37. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. S. Shehata (*) Pediatric Surgery Department, Alexandria University, Alexandria, Egypt

37.3 Anesthetic Considerations The laparoscopic Shehata technique is typically performed under general anesthesia and endotracheal intubation. The preferred age for the operation is between 6 and 12 months. A naso- or orogastric tube is placed to decompress the stomach for the duration of the procedure.

37.4 Operative Technique 37.4.1 Equipment • • • • •

5 mm optical trocar Atraumatic grasper Needle holder Monopolar hook (right angle) Non-absorbable 2-0 nonabsorbable, braided, Poly (ethylene terephthalate) for Anchoring stitch • 3-0 polyglycolic acid suture for closure of umbilical port

37.4.2 Positioning Supine position with the arms by the sides and the legs slightly spread apart. The head of the patient is located at the edge of the table and the monitor at the feet. The surgeon is standing at the head and the cameraman at the side contralateral to the testis side, scrub nurse on the other side. Trendelenburg position is adjusted after insertion of all trocars (Fig. 37.1).

37.4.3 Trocar Placement A 3 or 5 mm 30° is inserted through the umbilicus and pneumoperitoneum is established according to the patients age. Two working trocars 3 or 5  mm are inserted in the flanks

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_37

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S. Shehata

Fig. 37.1  Positioning of patient, surgeons and monitors

Legend

Patient

Monitor Surgeon Assistant Scrub nurse Instrument table

Legend

Working trocar Endoscope trocar Accessory trocar

Fig. 37.2  Trocars sites

The testis now is held in the direction of the contralateral deep ring and the peritoneum lateral to the testicular vessels is divided easily using monopolar hook diathermy with cutting current until the testis reach at or near the contralateral deep ring.

The Measuring Test and Decision Making If the testis reaches the contralateral deep ring without any degree of tension (and stays there after releasing the grasper) then this testis is suitable for one stage lap assisted orchiopexy without vessel interruption. However, this was found in less than 10% of cases of IAT. In the majority of cases, the testis reaches this measuring point with moderate degree of tension (it recoils back after releasing the grasper) and this will be suitable for using the Shehata technique.

lateral to the rectus muscle at the level of the umbilicus or lower in older children (Fig. 37.2).

37.4.4 Operative Milestones 37.4.4.1 First Stage Division of the Gubernaculum The operation begins with looking at the deep inguinal ring on both sides (Fig. 37.3). The items to look at includes: the patency of the processus vaginalis, the position and size of the testis, the vas deferens (VD) and testicular vessels (TV). When the testis is found, the first step is a careful division of the gubernaculum. The gubernaculum is divided by the hook using monopolar cutting current while pulling the gubernaculum in a cranial direction.

Mobilization and Fixation A non-absorbable 2-0 nonabsorbable, braided suture on round needle is passed from the outside through a small nick in the skin exactly one inch above and lateral to anterior superior iliac spine (ASIS) on the contralateral side. The end of the suture is held outside on a hemostat. The needle is held with a needle holder and a single stitch is taken in the lower pole of the testis, broad and superficial to incorporate the tunica albuginea (Fig. 37.4). During placement of the anchoring stitch, the testis is supported carefully with a fenestrated atraumatic grasper without completely closing the handles. The needle is exteriorized near the point of entry in the abdominal wall to ensure a good distance of the abdominal wall around 1  cm between entry and exit points to avoid slipping.

37  Laparoscopic Management of Intra-abdominal Testis (Shehata Technique) Fig. 37.3  Essential steps of the procedure. Reproduced from: Shehata S, Shalaby R, Ismail M, Abouheba M, Elrouby A. Staged laparoscopic tractionorchiopexy for intraabdominal testis (Shehata technique): Stretching the limits for preservation of testicular vasculature. J Pediatr Surg. 2016;51(2):211–5

a

201

b Abd. Textis Stage I : Fixation

c

d

Stage II : Orchiopexy Waiting period : Elongation

Fig. 37.5  Position of the testis before tying the stitch (Video 37.1 Shehata Technique (Essential Steps)). (▸ https://doi.org/10.1007/000-2w0) Fig. 37.4  Passing the stitch through Lower pole of the testis

37.4.4.3 Second Stage At this stage the testis is usually around 1–2 cm from the abdominal wall, gentle pressure from the outside will facilitate the abdominal wall to reach the testis. The suture is tied carefully on the outside and the knot is buried under the skin (Fig. 37.5).

37.4.4.2 Postoperative Care and Waiting Period The patient is allowed a liquid diet 4 h after recovery and is sent home the same day. No special analgesia or activity restriction is required. The waiting period is 12 weeks and the preoperative preparation for the second stage is the same as the first stage.

Assessment and Division of the Fixation Stitch The position and trocar sites correspond to the first stage. The site of fixation and the condition of the testis is explored. Usually there are no adhesions at the operative site. Internal herniation never occurred in over 12 years of experience. The laxity of the testicular vessels can be assessed by passing a grasper behind the middle of TV and pushing them towards the anterior abdominal wall (usually it reaches far towards the anterior abdominal wall compared to the first stage indicating significant lengthening). The fixation stitch is easily divided with scissors.

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Delivery in the Scrotum A scrotal incision is made and subdartos pouch is developed. A long curved clamp is inserted in the scrotum and introduced in the abdominal cavity under laparoscopic vision. (Fig.  37.6). The new deep ring is near the pubic tubercle (Prentiss maneuver). The testis is held from the gubernaculum side and delivered into the scrotum without twisting. The testis is secured in the subdartos pouch (Fig. 37.7). In older and obese children it is preferable to make a small inguinal incision, open the inguinal canal and deliver the testis to the inguinal incision before putting in the scrotum to avoid forcible pulling through the thick muscular abdominal wall.

S. Shehata

37.4.4.4 Postoperative Care Corresponds to the first stage. The patient will come for clinical and sonographic assessment at 3, 6 and 12 months after surgery.

37.5 Pearls/Tips & Tricks 1. The testis is slippery and difficult to hold with laparoscopic instruments; it is better to hold the gubernaculum rather than the testis to avoid its injury. 2. An easy way to get the needle and the thread out of the abdominal wall is to use the port closing instrument to grab the suture 3 cm away from the needle or using a loop of nonabsorbable polypropylene suture on a wide bore needle. 3. In bilateral IAT it is recommended to perform the procedure in three stages to avoid possible adhesions in case of bilateral simultaneous Shehata technique is performed. (1. first stage on the Right/2. second stage on the right + first stage on the Left/3. second stage on the Left)

37.6 Pitfalls & Ways to Avoid

Fig. 37.6  Curved clamp creating the new deep ring

1. Twisting of the pedicle; in order to avoid twisting of the pedicle, the bites in the testis should be adjusted with entry and exit points on the abdominal wall. 2. Narrow exit; The exit point through the abdominal wall should be enlarged by spreading the hemostat to avoid forcible traction on the testis. 3. Cutting through testis; the testis tissue is fragile, care must be taken when taking the bite in the testis to follow the curvature of the needle and to have enough length of the thread inside the abdomen before taking the bite. 4. Injury of the vas; In low lying IAT (within 2 cm from the deep ring) the VD is usually looping down in the deep ring. Extreme care is required while dividing the gubernaculum using monopolar hook diathermy with cutting current in short buzzes and under vision while pulling the gubernaculum upwards. 5. Injury bladder and inferior epigastric vessels; care must be taken during creating the new deep ring under vision to avoid injury of these two structures (Video 37.1).

Selected References

Fig. 37.7 Well vascularized testis reaching the scrotum without tension

1. Abouheba MAS, Younis W, Elsokary A, Roshdy W, Waheeb S.  Early clinical outcome of staged laparoscopic traction orchidopexy for abdominal testes. J Laparoendosc Adv Surg Tech A. 2019;29(4):531–7.

37  Laparoscopic Management of Intra-abdominal Testis (Shehata Technique) 2. Shehata S, Shalaby R, Ismail M, Abouheba M, Elrouby A. Staged laparoscopic traction-orchiopexy for intraabdominal testis (Shehata technique): Stretching the limits for preservation of testicular vasculature. J Pediatr Surg. 2016;51(2):211–5. 3. Shehata SM.  Laparoscopically assisted gradual controlled traction on the testicular vessels: a new concept in the management of abdominal testis. A preliminary report. Eur J Pediatr Surg. 2008;18(6):402–6.

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4. Elsherbeny M, Abdallah A, Abouzeid A, Ghanem W, Zaki A. Staged laparoscopic traction orchiopexy for intra-abdominal testis: Is it always feasible? J Pediatr Urol. 2018;14(3):267.e1–4. https://doi. org/10.1016/j.jpurol.2018.01.021. 5. Canning DA.  Re: Staged laparoscopic traction-orchiopexy for intraabdominal testis (Shehata technique): stretching the limits for preservation of testicular vasculature. J Urol. 2017;197(6):1563.

Two Stage Laparoscopic Assisted Fowler-Stephens Orchidopexy

38

Sameh Abdelhay and Amr Abdelhamid AbouZeid

38.1 Indications Laparoscopy is generally recommended for the diagnosis and management of all cases of nonpalpable undescended testes either unilateral or bilateral. The initial description by Fowler and Stephens in 1959 for management of intra-abdominal testis by cutting the spermatic vessels for gaining enough length to bring the testis in one stage into the scrotum showed 25% incidence of atrophy [1]. In 1984, Ransley modified the technique by doing the procedure in two stages: initial division of the vessels followed by mobilization of the testis into the scrotum 6 months later with better results and with no atrophy reported in his series [2]. Laparoscopy was first introduced to identify the location of a nonpalpable testis in 1976 by Cortesi [3] and remained a diagnostic modality for many surgeons until the report of spermatic vessel clipping as a first stage for a Fowler-­Stephens procedure by Bloom in 1991 [4]. Three years later, Jordan and Winslow reported the single-stage laparoscopy-­assisted orchiopexy [5]. In 1999, Hay et  al. described a laparoscopic classification for nonpalpable testis and used it as a guide for management [6], which was updated by Abouzeid et al. in 2012 [7]. In 2007, Hay described the effect of spermatic vessels ligation on the collateral circulation around the testis and showed the importance of preservation of the gubernaculum during the second stage [8].

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_38. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. S. Abdelhay (*) · A. A. AbouZeid Department of Pediatric Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt

38.2 Preoperative Workup and Considerations The diagnosis of nonpalpable testis is typically based on history of empty scrotum with failure to palpate the testis along its pathway in the inguinal region or ectopic sites. Local examination of the genitalia helps to exclude associated hypospadias and DSD. In obese or irritable boys inguinal examination may be difficult and inguinal ultrasound may be needed. Evacuation of the bladder in the OR is performed by a Credé maneuver or inserting a urethral catheter. Perioperative antibiotics are usually not indicated.

38.3 Anesthetic Considerations The procedure is performed under general anesthesia and endotracheal intubation. An elective operation is usually performed in an ambulatory setting for healthy infants older than 6 months.

38.4 Operative Technique 38.4.1 Equipment • 5 mm optical trocar—atraumatic grasper—diathermy hook or bipolar devise—Maryland forceps—10 mm trocar.

38.4.2 Positioning Supine positioning is used with legs spread slightly apart. The surgeon stands on the contralateral side, while the camera assistant at the head of table. The monitor is placed towards the infant’s feet to have the operative field in line

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_38

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between camera and monitor (Fig. 38.1). The scrotum should be prepped and exposed for placement of the testis.

38.4.3 Trocar Placement A 3 or 5 mm 30° scope is introduced through the umbilicus, and CO2 insufflation is established. The two working instruments are placed on either side at the lateral margin of the rectus muscle at the level or slightly below the umbilicus (Fig. 38.2).

38.4.4 Operative Milestones (Video 38.1) The procedure starts with an explorative laparoscopy and  identification of the testis [9], the configuration of the vas and vessels and their relation to the internal ring (Milestone 38.1, Fig. 38.3). In the first stage the spermatic vessels are exposed, dissected as high as possible, coagulated by bipolar or monopolar diathermy [10] and divided without any further dissection

(Milestone 38.2). Cutting of the vessels at this stage facilitates the dissection during the second stage. The second stage for mobilization of the testis to the scrotum is done 4–6 weeks later. We start by laparoscopic exploration to define the viability of the testis and the assess of the collaterals around the vas and the gubernaculum. The dissection usually starts by incising the lateral peritoneal leaflet near its base while the testis is pulled up. This is continued until the internal ring is reached to avoid division of the gubernaculum that may share the blood supply (Milestone 38.3). Then the medial peritoneal fold is incised at its base where it is attached to the posterior abdominal wall until it reaches the vas and its vessels (Milestone 38.4). Medialization of the gubernaculum may be needed in certain cases by cutting the medial lip of the internal ring. The testis is brought down to the scrotum by insertion of a 10 mm port through a scrotal incision emerging inside the abdomen between the inferior epigastric vessels and the medial umbilical ligament. This is done after gradual dilata-

Surgeon (contralateral side)

Camera man

Monitor

Fig. 38.1  Setup in the operation room Fig. 38.3 Laparoscopic classification according to AbouZeid et al. [7]. (IR: Internal inguinal ring; SV: Spermatic vessels; T: Testis; UL: Umbilical ligament; UB: Urinary bladder; VD: Vas deferens)

Fig. 38.2  Positioning of the ports

IR

IR

IR

T

UL

UL UB

UL UB

UB

VD

VD SV

VD

SV

SV

Type 1b

Type 1a

Type 2

IR

IR

IR

UL

T

UB

T

VD

VD SV

UB

Type 3b

UL UB

T

VD SV

Type 4a

UB

T

VD

SV

SV

Type 3a

IR UL

UL

Type 4b

38  Two Stage Laparoscopic Assisted Fowler-Stephens Orchidopexy

tion of the track or by using a grasper with or without a step trocar. With the help of an atraumatic grasper, the testis is pulled down into the scrotum and fixed to its bottom by 5/0 non-­ absorbable suture (Milestone 38.5). Alternatively, a small inguinal incision is made over the ipsilateral external inguinal ring to grab the testis directly from the abdomen. Then, the testis is tunneled to be fixed in a sub-dartos pouch in the scrotum (Milestone 38.6).

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38.5 Postoperative Care The procedure is done on a day case protocol and the patient is discharged the same day after tolerating oral feeds. Follow up is scheduled: the first visit after 1 week to check the wounds and the position of the testis; the second visit after 1 month to check the condition of the mobilized testis; and the third visit after 6 months.

38.6 Pearls/Tips & Tricks

Milestone 38.1  Identification of the testis, the configuration of the vas and vessels and their relation to the internal ring (Video 38.1. Fowler Stephens V2) (▸ https://doi.org/10.1007/000-2w1)

Milestone 38.2 (a) Exposure of spermatic vessels, (b, c) coagulation and cutting of vessels

a

Milestone 38.3  2nd Stage: Dissection of the medial and lateral leaflet

1. In bilateral conditions, when one testis is nonpalpable and the contralateral testis is palpable but undescended, we always expect to find a testis during laparoscopy. 2. We were always keen not to delay the second-stage procedure, and we tend to perform it as early as 4–6 weeks after the first stage, and from our experience, the testes at 6 weeks are always well vascularized. 3. During the first stage, dissection of the peritoneum off the testicular vessels can help to control bleeding and divide the vessels more comfortably especially in older children (Fig. 38.4).

b

c

Milestone 38.4  2nd stage: Incision of the medial peritoneal fold until it reaches the vas and its vessels

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4. The collaterals around the testis settled after cutting of the spermatic vessels, vary from patient to patient, being evident mainly around the vas or around the gubernaculum or both, so preservation of the gubernaculum is important. 5. An inguinal incision for delivery of the testis after its mobilization may be needed in some cases when the testis is big as in adolescents or in cases with looping vas. 6. In bilateral abdominal testis our protocol is: initial coagulation and division of the vessels on both sides followed 4–6 weeks later by laparoscopic orchidopexy for both in the same session or in different sessions.

38.7 Pitfalls & Ways to Avoid

2. For a ‘long looping vas’ variety, the vas may be injured while cutting the gubernaculum. Leaving the gubernaculum intact is feasible in nearly all cases. The higher the testis, the longer the gubernaculum; and its medialization by cutting the medial lip of the internal ring can help in gaining more length for scrotal placement of the testis. Some authors prefer to perform the second stage orchiopexy in such cases via an open inguinal approach. 3. The abdominal testis may be located high near by the kidney so proper exploration is needed following the vas and retracting the intestine in order not to miss its presence. 4. The urinary bladder should be empty to avoid its injury while rerouting of the testis to the scrotum.

1. While rerouting of the testis during the second stage, avoid passing it medial to the medial umbilical ligament to avoid injury of the urinary bladder while creating the new exit site of the testis.

Milestone 38.5  The testis is brought down to the scrotum by insertion of a 10 mm port or grasper through a scrotal incision emerging inside the abdomen between the inferior epigastric vessels and the medial umbilical ligament

Milestone 38.6 (a) Trans scrotal approach, (b, c) Inguinal approach for pulling the testis to the scrotum

a

Fig. 38.4  6 months after laparoscopic two stage Fowler-Stephen orchidopexy

b

c

38  Two Stage Laparoscopic Assisted Fowler-Stephens Orchidopexy

References 1. Fowler R, Stephens FD.  The role of testicular vascular anatomy in the salvage of high undescended testis. Aust N Z J Surg. 1959;29:92–106. 2. Ransley PG, Vordermark JS, Caldamone AA, Bellinger MF.  A staged Fowler-Stephens procedure. World J Urol. 1984;2:266–26. 3. Cortesi N, Ferrari P, Zambarda E, Manenti A, Baldini A, Morano FP, et al. Diagnosis of bilateral abdominal crytorchidism by laparoscopy. Endoscopy. 1976;8:33–4. 4. Bloom DA. Two-step orchidopexy with pelviscopic clip ligation of the spermatic vessels. J Urol. 1991;145:1030–3. 5. Jordan GH, Winslow BH.  Laparoscopic single stage and staged orchidopexy. J Urol. 1994;152:1249–52.

209 6. Hay SA, Soliman HA, Abdel Rahman AH, Bassiouny IE. Laparoscopic classification and treatment of the impalpable testis. Pediatr Surg Int. 1999;15(8):570–2. 7. AbouZeid AA, Safoury HS, Hay SA.  Laparoscopic classification of the impalpable testis: an update. Ann Pediatr Surg. 2012;8(4):116–22. 8. Hay SA.  Collateral circulation after spermatic vessel ligation for abdominal testis and its impact on staged laparoscopically assisted orchiopexy. J Laparoendosc Adv Surg Tech A. 2007;17(1):124–7. 9. Dave S, Manaboriboon N, Braga LHP, et al. Open versus laparoscopic staged Fowler-Stephens orchiopexy: impact of long loop vas. J Urol. 2009;182:2435–9. 10. AbouZeid AA, Moussa MH, Shalaby MS, Safoury HS, El-naggar O, Hay SA.  Feasibility and safety of monopolar diathermy as an alternative to clip ligation in laparoscopic Fowler-Stephens orchiopexy. J Pediatr Surg. 2012;47:1907–12.

Part VIII Thorax

Thoracoscopic Tracheoesophageal Fistula and Esophageal Atresia Repair

39

Sarah W. Lai and Steve Rothenberg

39.1 Indications for Thoracoscopic Approach to Tracheoesophageal Fistula and Esophageal Atresia Thoracoscopic repair is indicated for tracheoesophageal fistula (TEF) and esophageal atresia (EA) if the infant is hemodynamically stable, the anesthesiologist is comfortable with management of chest insufflation, and the surgeon is experienced in working efficiently in a small space. Thoracoscopy allows for rapid identification of the TEF for ligation, minimizing acute gastric dilation due to prolonged ventilation of the fistula. Although absolute lower weight limits for thoracoscopic repair have not been established, significant prematurity and birth weight 15% thoracic volume to allow for lung re-­ connective disorders. expansion [2]. The etiology of primary spontaneous pneumothorax is caused by rupture of lung bullae or blebs. Bullae are cystlike structures, mostly located at the apex of the upper lobes. 44.2 Indications for Thoracoscopic The incidence of spontaneous pneumothorax is estimated to Approach to Treat Spontaneous be 7.4–18 in 100,000 in males and 1.2–6 in 100,000 females Pneumothorax with a mean age of presentation between 13.5 and 16.6 years [1]. Surgical treatment is suggested for persistent chest tube air SPS presents with acute onset of sharp pain that worsens leak of a unilateral SPS lasting longer than 4 days, recurrent with inspiration with or without shortness of breath or tachy- ipsilateral pneumothorax, initial bilateral SPS, hemothorax pnea. SPS can progress into tension pneumothorax with evi- or SPS in patients with low/high pressure environment like dence of tracheal deviation, hypotension, cyanosis, and pilots or divers, as well as children and youths who plan to jugular venous distension. The latter is an absolute emer- engage in such activities [3]. gency and warrants immediate ipsilateral decompression. Video-assisted thoracoscopy (VATS) offers an excelThe diagnosis of Pneumothorax is made by a thorough lent minimally invasive treatment option to resect affected history, physical exam and an upright single view anteropos- lung areas. Concomitant mechanical pleurodesis or pleuterior chest radiograph. rectomy is often applied in an attempt to reduce recurrence [4]. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_44. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. F. G. Seifarth Pediatric Surgery, West Virginia University, Kalispell Regional Healthcare, Morgantown, WV, USA e-mail: [email protected]; [email protected] O. J. Muensterer (*) Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

44.3 Preoperative Workup and Considerations Anesthetic considerations depend in large on the clinical condition of the patient. Unilateral lung ventilation by means of main-stem intubation or application of a double lumen tube facilitates thoracoscopy, but is not mandatory. One must outweigh the advantage of increased workspace against decreased lung inflation which may render visualization of blebs more challenging. Positioning on a soft shoulder roll prevents damage to the axillary nerve plexus.

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_44

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Fig. 44.1  Positioning of patient, surgeons and monitors

44.4 Operative Technique 44.4.1 Equipment • • • • • • •

Two 5 mm thoracoscopic trocars One 12 mm trocar 30° 5 mm endoscope 5 mm soft bowel grasper 5 mm atraumatic grasper 10 mm in line endo-GIA stapler Age-appropriate chest tube

44.4.2 Positioning • Full lateral position with exposed affected side • Careful padding and securing the patient on operating table (Fig. 44.1)

Fig. 44.2  Trocar placement

44.4.3 Trocar Placement

44.4.4 Operative Milestones

• Sixth intercostal space, midaxillary: 5 mm • Seventh intercostal space, posterior axillary line 12 mm • Seventh intercostal space, anterior axillary line: 5  mm (Fig. 44.2)

The Surgeon and assistant are usually located on the opposite side of the patient with monitors on either side of the patient’s head.

44  Treatment for Spontaneous Pneumothorax

237

Aseptic technique is applied. The initial trocar can be placed through the previous chest tube site or in the mid-­ axillary line in the sixth intercostal space. Pneumothorax is maintained with low flow CO2 inflation at a pressure of 5–6 mmHg or about 1 mmHg over the applied positiveend-­ expiratory pressure. Triangular placement of two 5  mm trocars in adjacent intercostal spaces is then performed under thoracoscopic vision. Depending on the size of the used stapler, a 12  mm port must be placed. Some surgeons omit usage of a third port and insert blunt graspers via a single stab incision. Blebs are identified and secured with an atraumatic grasper (Milestone 44.1) while a non-anatomic resection is being performed with firings of the 10mm stapler (Milestone 44.2). The specimen can be retracted via on of the stab incisions or the 12 mm port site.

For the pleurectomy, the parietal pleura is bilaterally scored and mechanically stripped (Milestone 44.3). The “spaghetti technique” helps removing the pleura by grasping the parietal pleura and rolling it over the instrument (Milestone 44.4). Caution must be taken not to injure the superior vena cava, the subclavian vein, or the great vessels. A leak test is performed by filling the thoracic cavity with sterile normal saline as the anesthesiologist is asked to re-­ inflate the lung. Working ports are removed under direct visualization to recognize bleeding from inadvertent injury to the intercostal vessels. A 16 or 18 French chest tube is placed through one of the incisions and advanced into the cephalad chest under thoracoscopic guidance. Port sites are closed in layers with absorbable sutures. Rib blocks with long lasting local anesthetic are applied.

Milestone 44.1  Blebs are identified and secured with an atraumatic grasper (Video 44.1 VAPE_Final video with narration complete converted_20200407om). (▸ https://doi.org/10.1007/000-2w7)

Milestone 44.3  The pleura is bilaterally scored using the electrocautery hook

Milestone 44.2  A non-anatomic resection is being performed with a 10 mm endoscopic stapler-cutter

Milestone 44.4  The “spaghetti technique” helps removing the pleura by grasping the parietal pleura and rolling it over the instrument

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44.5 Postoperative Care

44.7 Pitfalls & Ways to Avoid

The patient is admitted for overnight observation with the chest tube to continuous suction. An anterioposterior chest radiograph should be obtained within 12 h. The chest tube can be removed at the bedside if the lung has fully expanded and no air leak is appreciated. Full expansion of the lung is confirmed with another radiograph after removal of the tube. Patients can be discharged if pain is well controlled. Reduced physical activity for 4 weeks is recommended. A repeat chest X-ray should be obtained 2 weeks after discharge.

1. Avoid damage to the neurovascular intercostal bundle during trocar placement by placing ports above the ribs. 2. Sharp trocar placement carries a high risk for injury of the intercostal vessels and lung parenchyma. 3. Visualize the entire visceral pleura to avoid missed blebs. 4. Carefully inspect the trocar sites when removing the ports for signs of intercostal bleeding. 5. Be aware of the thoracic sympathetic chain, superior vena cava, the subclavian vein, or the great vessels and avoid injury (Video 44.1).

44.6 Pearls/Tips & Tricks

References

1. Lung inflation during thoracoscopy may reveal blebs that can be missed during lung exclusion. 2. The “spaghetti technique” allows a controlled stripping of the parietal pleura. 3. Fill the pleural space with normal saline and re-inflate the lung under thoracoscopic inspection to detect air leaks. 4. Intercostal bleeding can be controlled by pressure of a chest tube through the affected trocar site. 5. Insufflation should start with low flow and low pressures. Start at 4–5 mmHg. Pressure can be gradually increased to 7–8 if not enough working space available or single lung ventilation not achieved.

1. Dotson K, Johnson LH.  Pediatric spontaneous pneumothorax. Pediatr Emerg Care. 2012;28(7):715–20. Quiz 21–3 2. Chen JS, Chan WK, Tsai KT, Hsu HH, Lin CY, Yuan A, et  al. Simple aspiration and drainage and intrapleural minocycline pleurodesis versus simple aspiration and drainage for the initial treatment of primary spontaneous pneumothorax: an open-label, parallel-group, prospective, randomised, controlled trial. Lancet. 2013;381(9874):1277–82. 3. Robinson PD, Blackburn C, Babl FE, Gamage L, Schutz J, Nogajski R, et  al. Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series. Arch Dis Child. 2015;100(10):918–23. 4. Yeung F, Chung PHY, Hung ELY, Yuen CS, Tam PKH, Wong KKY. Surgical intervention for primary spontaneous pneumothorax in pediatric population: when and why? J Laparoendosc Adv Surg Tech A. 2017;27(8):841–4.

Pulmonary Sequestrations

45

Peter Zimmermann, Illya Martynov, and Martin Lacher

45.1 Indications for Thoracoscopic Approach to Pulmonary Sequestrations Pulmonary Sequestration (PS) consists of lung parenchyma that does not regularly communicate with the normal tracheobronchial tree and is supplied by aberrant systemic vessels, mainly from the thoracic and abdominal aorta. PS is classified into intralobar sequestration (ILS) and extralobar sequestration (ELS). ELS (~25%) has its own independent visceral pleura and is completely separated from the lung, while ILS has the same visceral pleura as the lung and may communicate to a normal bronchus, which increases the risk for infection [1]. Symptoms may include respiratory distress and recurrent respiratory tract infections. Thoracoscopic resection of PS is feasible and safe [2, 3]. Because of the risk of recurrent infection or malignant degeneration later in life elective, resection between 6 and 12 months of age is warranted. ELS resection is a straightforward procedure. ILS resection, in general performed as a formal lobectomy, is more demanding. However, in the case of focal disease, segmental resection has been proposed as a safe alternative [4].

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_45. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App.

45.2 Preoperative Workup and Considerations Newborns with a prenatally diagnosed congenital lung malformation (CLM) should have a postnatal chest X-ray. Asymptomatic children are usually discharged and a computed tomographic angiographic scan (CT-A) or a magnetic resonance imaging angiographic scan (MRI-A) within the first 6 months of life is performed. A systemic blood supply to the lesion may be diagnostic for PS, but the differential diagnosis includes a hybrid lesion, a mix between congenital pulmonary airway malformations (CPAM) and PS.

45.3 Anesthetic Considerations Routine pulse oximetry is used. In experienced hands, central venous lines, arterial lines, and Foley catheters are not routinely required. Typed and cross-matched blood should be available in the operating room. Single-lung ventilation of the opposite side is valuable when the size of the child permits. This can be achieved by intubation with a double lumen endotracheal tube which can be used in pediatric patients as young as 8 years old. In infants and smaller children single-­ lung ventilation can be obtained by mainstem intubation of the contralateral side or by extraluminal placement of a bronchial blocker [5]. If this is not achievable, the ipsilateral lung can be collapsed by insufflation of CO2 into the pleural space at a pressure slightly above the positive end-expiratory pressure. A nasogastric tube is routinely placed, and a perioperative antibiotic prophylaxis with a first-generation cephalosporin is administered [6]. There is no need for epidural or spinal anesthesia.

P. Zimmermann (*) · I. Martynov · M. Lacher Department of Pediatric Surgery, University Hospital of Leipzig, Leipzig, Germany e-mail: [email protected]; [email protected]; [email protected] © Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_45

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45.4 Operative Technique 45.4.1 Equipment • 5 mm camera port • 5 mm camera (30–45°) • Two 3–5 mm working ports (depending on patient size, 5  mm for endoclips and 5  mm sealing device, alternatively 3 mm sealing device) • 5–12 mm working port (for endoscopic stapler, can also passed directly into the chest without a port) • Two atraumatic graspers • Kelly/Maryland dissector • Needle holder • Monopolar hook cautery • Irrigator/aspirator • Endoscopic Clips • Sealing device • Endoscopic stapler, 5 mm or 12 mm • Specimen retrieval bag

45.4.2 Positioning Lateral decubitus position on the contralateral side with adequate padding of all bony prominences supported on a beanbag with an axillary roll underneath. Alternatively, small gel rolls may be placed anteriorly and posteriorly in younger children. Before draping, the table should be tilted to both sides for stable positioning of the patient. The surgeon and assistant stand at the front of the patient with the assistant above the surgeon near the head of the patient.

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veins are meticulously dissected. If feasible, it is recommended to ligate the arteries first and the veins afterwards to avoid congestion of the lung parenchyma (Milestone 45.2). The vessels are suture ligated or clipped twice centrally and once peripherally (Milestone 45.3). If clips are used, locking-­clips are recommended as the risk for clip-dislocation is lower. After ligation, the vessel is cut in two steps to assure that the ligation is sufficient (Milestone 45.4). In this way, the vessel still be controlled

Milestone 45.1  Identification of the aberrant systemic blood vessel and dissection of the pleura overlying the vessels (Video 45.1 Thoracoscopic treatment of pulmonary sequestration). (▸ https://doi.org/10.1007/000-2w8)

45.4.3 Trocar Placement A 5 mm port is introduced in the 5th or 6th intercostal space in the mid- to anterior axillary line and a 5 mm 30° camera is introduced. CO2 insufflation is started (1L/min; 4  mmHg). The location of the major fissure dictates the positioning of the working ports which are inserted in the anterior axillary line above and below the camera port between the 5th and the 8th or 9th interspaces. If the use of an endoscopic stapler is planned, an adequately-sized port (5  mm or 12  mm) is placed at the lower site during the operation. An additional port or instrument without port for retraction of the lung may be inserted if necessary.

Milestone 45.2  If feasible it is recommended to ligate the arteries first and the veins afterwards to avoid congestion of the EPS. Retraction of the vessels with a soft silicone rubber band (“vessel-loop”) leads to a smaller diameter of the vessel making the ligation with endoclips easier

45.4.4 Operative Milestones After identification of the aberrant systemic blood vessel, the pleura over the vessels is carefully incised using scissors and monopolar hook cautery (Milestone 45.1). The arteries and

Milestone 45.3  The vessels are suture ligated or clipped twice centrally and once peripherally

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postoperative day. The child can be discharged when comfortable on oral pain medication and tolerating adequate oral intake.

45.6 Pearls/Tips & Tricks

b

Milestone 45.4 (a, b) After ligation the vessel is cut in two steps to assure that the ligation is sufficient

1. Positioning of the working ports is extremely important and is dictated by the location of the fissure. 2. A clear understanding of the anatomy is paramount. 3. Ligate the artery first and the veins afterwards (Milestone 45.2). Otherwise there will be congestion of the lung parenchyma making manipulation more difficult with more risk for bleeding. 4. Retraction of the vessels with a soft silicone rubber band (“vessel-loop”) leads to a smaller diameter of the vessel making the ligation with endoclips easier (Milestone 45.2). 5. Dissection should follow a clear orderly fashion from anterior to posterior. 6. Tilting the operating table improves the exposure by using gravity retracting the lung.

45.7 Pitfalls & Ways to Avoid if bleeding is noticed. With ligation and dissection of all supplying vessels, the resection of ELS is accomplished and the specimen is removed with or without endoscopic specimen bag. For ILS, a formal lobectomy (in majority the left lower lobe) is recommended unless the surgeon feels comfortable to perform a segmentectomy. The aberrant systemic blood vessel is usually identified during the mobilization of the inferior pulmonary ligament. After secure ligation of the vessel the inferior pulmonary vein is dissected for later ligation. By dissection of the major fissure from anterior to posterior, the pulmonary artery is identified. Completion of the fissure even by a sealing device or an endoscopic stapler maybe necessary. After adequate isolation, the pulmonary artery is ligated with endoclips or with a stapler (vascular load). Finally, the bronchus to the lower lobe (in case of the most frequent ILS) which lies directly behind the pulmonary artery is seen. The inferior pulmonary vein is ligated and then the bronchus is divided with an endoscopic stapler. In smaller children the bronchus may be closed with endoclips or by suture ligation. The specimen is removed using an endoscopic specimen bag. A chest tube is placed through the lowest trocar site and the incisions are closed in two layers with absorbable suture.

45.5 Postoperative Care The patient is generally extubatable in the OR.  Intermittent intravenous analgesia is used until the chest tube is removed. If there is no air leak, the chest tube can be removed on the first

1. Avoid unnecessary manipulation of the lung parenchyma which tends to bleed easily 2. Retraction of an insufficiently ligated artery into the abdominal cavity may lead to dangerous bleeding that can only be controlled by quick abdominal intervention. Vessels should therefore be clipped twice centrally using locking endoclips. Also, they should be cut in two steps to assure that the ligation is sufficient before complete transection (Milestone 45.4a, b).

References 1. Puligandla PS, Laberge JM. Congenital lung lesions. Clin Perinatol. 2012;39:331–47. 2. Rothenberg SS, Middlesworth W, Kadennhe-Chiweshe A, et  al. Two decades of experience with thoracoscopic lobectomy in infants and children: standardizing techniques for advanced thoracoscopic surgery. J Laparoendosc Adv Surg Tech A. 2015;25:423–8. 3. Adams S, et al. Does thoracoscopy have advantages over open surgery for asymptomatic congenital lung malformations? An analysis of 1626 resections. J Pediatr Surg. 2017;52:247–51. 4. Bagrodia N, Cassel S, Liao J, et  al. Segmental resection for the treatment of congenitalpulmonary malformations. J Pediatr Surg. 2014;49:905–9. 5. Mohtar S, Hui TWC, Irwin MG.  Anesthetic management of thoracoscopic resection of lung lesions in small children. Paediatr Anaesth. 2018;28(11):1035–42. https://doi.org/10.1111/pan.13502. [Epub ahead of print], Hammer GB. Pediatric thoracic anesthesia. Anesth Analg.2001;92:144 9-1464) 6. Chang SH, Krupnick AS.  Perioperative antibiotics in thoracic surgery. Thorac Surg Clin. 2012;22(1):35–45, vi. https://doi. org/10.1016/j.thorsurg.2011.08.012. Epub 2011 Oct 20

Video-Assisted Thoracoscopic Approach for Mediastinal Mass (VATS)

46

Alexander Sterlin, Oliver J. Muensterer, and Jan Goedeke

46.1 Indications for Video-Assisted Thoracoscopic Approach to Mediastinal Mass The mediastinum is the most common location of chest masses in the pediatric population. Mediastinal masses may be nonvascular or vascular and represent congenital anomalies, infections, benign and malignant neoplasms, and pseudomasses. The anterior mediastinum contains the thymus gland and thus is the usual location for tumors of the thymus. Other common tumors of the anterior mediastinum are lymphomas and germ cell tumors. Masses in the middle mediastinum most commonly represent lymph nodes that are enlarged by a malignant, infectious, or inflammatory process. Masses in the posterior mediastinum are usually tumors or cysts originating from either the nerves that are present in this area (neurogenic tumors, neuroblastoma, ganglioneuroblastoma) or from the esophagus (foregut duplication cysts). Minimally invasive procedures such as mediastinal mass biopsy or even a mass resection are often necessary prior to any treatment or during the course of therapy. These procedures may include imaging guided fine-­needle biopsy, anterior mediastinotomy (Chamberlain Procedure), Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_46. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. A. Sterlin · J. Goedeke (*) Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany e-mail: [email protected]; [email protected] O. J. Muensterer Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University Munich, Munich, Germany e-mail: [email protected]

mediastinoscopy, and video-assisted thorascopic surgery (VATS). The location of the mass, surgeon’s experience and the technical equipment are important aspects in choosing the procedure type. Video-assisted thoracoscopic surgery is available as standard in most pediatric surgical clinics and is therefore mostly used for childhood mediastinal biopsies and mass resections.

46.2 Preoperative Workup and Considerations The preoperative procedure is usually patient-specific based on the underlying disease and should always be determined team based (pediatric surgeon, radiologist, oncologist, infectiologist…). Prior to any operation available imaging should be reviewed in detail to plan the procedure and to assess for important risks such as tracheal and superior vena cava compression. Also coagulation parameters should be checked preoperatively, and packed red blood cells should be crossed because, under certain circumstances, significant bleeding may occur intraoperatively.

46.3 Anesthetic Considerations On the OR day the patient should be kept NPO per standard protocol. Anesthesia should be performed by an experienced pediatric anesthesiologist as anesthetic management of children with mediastinal masses is very challenging and it is associated with significant risks of severe airway and/or cardiovascular compromise and bleeding, and may lead to significant morbidity and even death [1, 2]. Therefore, in many clinics, there are specially established protocols for mediastinal mass, demanding for example the use of peripheral IV accesses at different extremities and arterial blood pressure control.

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VATS is typically performed under general endotracheal anesthesia with dual lung ventilation. To obtain a sufficient mediastinal view it is usually sufficient to use a slightly higher insufflation pressure during thoracoscopy than PEEP. The corresponding lung partially collapses quite easily. In our experience only in selected cases single-lung ventilation is really necessary. Severe intraoperative bleeding is rare, but having blood available is advisable due to the complex nature of the procedure. Hypothermia should be avoided. A nasogastric tube and a urinary catheter are surgically not required. However, some anesthesiologists prefer a transurethral bladder catheter for intraoperative circulatory monitoring. A perioperative antibiotic prophylaxis can be done according to general recommendations.

46.4 Operative Technique 46.4.1 Equipment • Three trocars (depending on the planned procedure 2 mm, 3 mm, 5 mm or 10 mm). • 3 or 5 mm 30° or 45° telescope. • 2 mm, 3 mm or 5 mm Maryland dissector. • 2 mm, 3 mm or 5 mm atraumatic grasper. • 3 or 5  mm laparoscopic cautery hook or 5  mm sealer/ divider. In the future we will also test a 3 mm sealer for this purpose. However, there are currently no experiences on our part. • 5 or 10 mm endobag. • 5 mm endoscopic clip applier (in case of bleedings).

46.4.2 Positioning Positioning depends on the site of the lesion and the type of procedure. Thoracoscopic procedures should be performed with the patient in a position that allows for the greatest access to the areas of interest and uses gravity to aid in keeping the uninvolved lung or other tissue out of the field of view. For anterior mediastinal masses the patient should be placed supine with the affected side elevated 20–30° or in lateral position. For posterior mediastinal masses the patient should be placed in a modified prone position with the effected side elevated slightly. The arms are usually abducted and elevated. The patient should be secured by tape or vacuum bean bag positioner in case of older patients to allow for safe positioning. The surgeon should stand on the side of the table opposite the area to be addressed so that he can work in line with the camera. In most mediastinal mass cases, it is preferential to have the assistant on the same side of the table as the surgeon so that he is not working paradoxically (against the camera) (Fig. 46.1). The scrub nurse is positioned lateral or in opposite to the surgeon (Fig.  46.1). The chest is prepped and draped from the jugulum to the upper abdomen.

46.4.3 Trocar Placement Trocars should be placed in accordance with the baseball diamond concept with the camera trocar fixed caudal between the working instrument trocars. The camera trocar is usually placed in the midaxillary line in the fourth to sixth intercostal

Fig. 46.1  Positioning of patient, surgeons and monitors Legend

Patient

Monitor Surgeon Assistant Scrub nurse Instrument table

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space (depending on the size of the child and lesion location). Initial insufflation is 3–6  mmHg of pressure (usually 1 or 2 mmHg above PEEP) using CO2. During the procedure, the insufflation pressure can be increased temporarily to provide more sufficient working space. This maneuver must be done in cooperation with the anesthesiologist in order to prevent venous return failure and potential decrease of regional cerebral oxygen saturation in neonates and infants [3]. Under vision, the working instrument trocars are placed in the anterior and posterior axillary line in triangular configuration. All port sites are injected with local anesthesia (for instance 0.25% bupivacaine) prior to the trocar placement (Fig. 46.2).

46.4.4 Operative Milestones Before any surgical manipulation a thorough imaging review and inspection of the thoracic cavity and mediastinum is important (Video 46.1). If possible the surgeon

Legend

Camera trocar Working trocars

Fig. 46.2  Positioning of the trocars

Milestone 46.1  Thorough review of radiologic imaging characteristics preoperatively (Video 46.1 Mediastinal mass). (▸ https://doi.org/10.1007/000-2w9)

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should reliably identify important orienting structures, such as the N. phrenicus, N. vagus, and central vascular structures (Milestones 46.1 and 46.2). For biopsies usually the part of the mass with most distance to the great vessels has to be biopsied in order to avoid massive bleeding. If there remains uncertainty, the planned biopsy site can be aspirated using a small needle to ensure it is not a vascular structure. Some surgeons report that it might be helpful to place a suture through the site from which the biopsy is to be taken as this would allow manipulation of the site without tissue trauma to the resulting specimen. In our experience this procedure is rarely necessary. Biopsy could be taken in different variants. One could use a hook cautery to outline the biopsy area and perform the biopsy with a scissor connected to cautery. Sealer/divider systems could also be used (Milestone 46.3). The specimen should be placed in a retrieval bag to prevent spillage and contamination of the thoracic cavity and chest wall (Milestone 46.4). It is important to keep in mind that numerous of histologic studies could be needed to determine the diagnosis so an adequate volume of the tissue is required. Similar to just a biopsy, several complete mass resections, as in mediastinal teratoma or ganglioneuroblastoma, are possible. It is recommended to dissect close to the mass in order to minimize the risk of unnecessary trauma. Intraoperative placement of a chest drain is usually not required. Only in cases of major tumor resection or expected risk of pneumothorax a chest drain might be placed through the most caudal incision in direction towards the apex. The drain should be attached to an underwater seal, below the level of the chest. If there remains no visible bleeding the final part of the operation might begin. Using positive pressure ventilation of the lungs the artificial applied pneumothorax is largely relieved while trocar valves are opened and trocars are subsequently retreated. The small incisions are closed in layers with absorbable sutures (4–0 polyglactin suture & 5–0 Poliglecapron 25-Copolymer).

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Milestone 46.2 Thorough inspection of the thoracic cavity and mediastinum preoperatively and during surgery

Milestone 46.3 A mediastinal mass biopsy is taken using hook cautery (left image) or LigaSure™ (right image)

46.5 Postoperative Care Postoperative chest X-ray is mandatory within the first 6 h after surgery (AP; if necessary also lateral), to rule out any mass effect or pneumothorax. Intensive care monitoring is usually not required postoperatively. Postoperative cardiac and pulse oximetry monitoring over 6–24  h on the floor is usually sufficient and

recommended to watch for the development of tachycardia (potential postoperative bleeding). Pain control is achieved by in-house standard, most likely by oral pain medication. A clear liquids diet is instituted upon arrival to the floor with advancement to a regular diet as tolerated. Maintenance intravenous fluids are weaned as the fluid intake advances. A postoperative antibiotic prophylaxis is usually not necessary in regular cases. It is important, especially

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3. Position the child accurately and use gravity, which allows the lung to fall away from the field of dissection to assist with the dissection. 4. Expose major vessels and phrenic nerve securely. In case of any doubt the planned biopsy site can be aspirated using a small needle to ensure it is not a vascular structure. 5. The majority of the dissection can be accomplished bluntly (suction-irrigation device or blunt forceps). 6. Use a specimen retrieval bag to avoid unnecessary spillage and contamination of the pleural cavity. 7. Do not hesitate to convert from thoracoscopy to thoracotomy in unclear situations or any case of emergency.

46.7 Pitfalls & Ways to Avoid

Milestone 46.4  Evacuation of a mediastinal tumor specimen by endoscopic retrieval bag

in patients with compromised lung function, to start early and aggressive postoperative pulmonary toilet, which could be performed under physiotherapeutic guidance. Most children can be discharged from the hospital after full mobilization.

46.6 Pearls/Tips & Tricks 1. The surgeon must closely communicate with the anesthesiologist during the OR as the anesthetic management of children with mediastinal masses is very challenging and it is associated with significant risks of severe airway and/ or cardiovascular compromise and bleeding. 2. Preoperative identification of the tumor and its positioning according to great vessels with MRI and/or CT-scans may help to minimize the risk of the massive bleeding.

1. Excessive insufflation pressure may cause diminished venous return and sudden airway and cardiovascular collapse. Do not increase the intrathoracic pressure to intense and look for other ways for better operative field visualization (for example positioning of the patient) instead. 2. Keep in mind that numerous of histologic studies can be needed to determine the diagnosis so an adequate volume of the tissue is required. Discuss the required volume with pathologist prior to the operation. 3. Massive intraoperative bleeding can occur. It can be helpful to have endoscopic clip applier in your arsenal.

References 1. Rothenberg SS.  Thoracoscopy in infants and children. Semin Pediatr Surg. 1998;7:194–201. 2. Dave N, Fernandes S. Anaesthetic implications of paediatric thoracoscopy. J Minim Access Surg. 2005 Mar;1(1):8–14. 3. Neunhoeffer F, Warmann SW, Hofbeck M, Müller A, Fideler F, Seitz G, Schuhmann MU, Kirschner HJ, Kumpf M, Fuchs J.  Elevated intrathoracic CO2 pressure during thoracoscopic surgery decreases regional cerebral oxygen saturation in neonates and infants-A pilot study. Paediatr Anaesth. 2017 Jul;27(7):752–9.

Thoracoscopic Thymectomy

47

Phillip Benson Ham III, Walter Pipkin, Kosmas Iliadis, and Spyros P. Spyrakos

47.1 Introduction The thymus is a bi-lobar, soft glandular structure in the anterior mediastinum. It is responsible for immune development and tolerance. Thymic pathology accounts for less than half of mediastinal masses. However, patients with thymic pathology often require thymectomy. Fortunately, many thymic lesions are amenable to minimally invasive resection.

47.2 Important Anatomic Landmarks Thymic lobes expand lateral to the midline and are larger inferiorly. Each lobe has a tail that extends towards the thyroid in the neck and is part of the thyro-thymic ligament. These course just anterior to the left brachiocephalic vein and superior vena cava. The thoracic duct typically lies posterior to the left thymic tail just before it drains into the left internal jugular vein and left brachiocephalic vein junction. Small arterial branches come from the inferior thyroid artery and internal thoracic arteries with similar venous drainage. Occasionally, it is supplied by the superior thyroid Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_47. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. P. B. Ham III (*) John R. Oishei Children’s Hospital, Buffalo, NY, USA W. Pipkin Children’s Hospital of Georgia, Augusta, GA, USA e-mail: [email protected] K. Iliadis Hygeia Diagnostic and Therapeutic Center of Athens, Athens, Greece S. P. Spyrakos Helena Venizelou-Alexandra General and Maternity Hospital, Attica, Greece

artery, aortic arch, brachiocephalic, or left common carotid artery. The phrenic nerves are lateral and posterior, running along the anterior pericardium.

47.3 Indications for Thoracoscopic Approach to Thymus Thymic cysts are resected if they are symptomatic or to exclude other diagnoses. Thymic hyperplasia is resected if symptomatic. Thymectomy is indicated in juvenile and adult myasthenia gravis patients who are generalized acetylcholine receptor antibody positive and have unsatisfactory response to treatment. Children are particularly at risk for steroid side effects such as poor growth, poor bone mineralization, and infection. Thymectomy for MG is an elective procedure as there can be a long delay to respond to removal. Complete surgical excision is indicated for Masaoka stage 1–3 thymoma. NCCN guidelines state there is no long-term data on minimally invasive procedures, but VATS can be considered for clinical stage I and II lesions. Some suggest using a VATS approach ideally when the patient has no pericardial or great vessel involvement and for tumors less than 3 cm [1]. Surgical debulking is indicated for stage 4, followed by radiotherapy and chemotherapy. The thoracoscopic approach has been safely used even as young as 1.6 years [2]. The mean operative time in one pediatric study was 120 min [3].

47.4 Preoperative Workup and Anaesthetic Consideration Large masses can result in loss of airway and hemodynamic instability with induction as general anesthesia removes the ability to compensate. This should be assessed and planned for preoperatively. Stridor and tracheal cross section less than 50% are predictive of increased risk [4, 5]. Steroids, chemotherapy or radiation therapy can be used to shrink the mass in high risk patients prior to operative intervention. For

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patients with myasthenia gravis, preoperative opioids and benzodiazepines can have prolonged effects and are best avoided. Succinylcholine should not be used and nondepolarizing neuromuscular blocking agents should be used judiciously with train of four monitoring. Sugammadex selectively binds and inactivates rocuronium and vecuronium and can be used for more rapid reversal. After induction of general anesthesia and endotracheal intubation, collapse of the ipsilateral lung can be achieved either by CO2 insufflation or a bronchial blocker.

47.5 Operative Technique 47.5.1 Equipment • Two or three 5 mm trocars and one 12- or 15-mm trocar depending on the size of thymus • 5 mm, 30° telescope

• • • • • •

5 mm energy device 5 mm hook monopolar cautery 5 and 10 mm endoclips 10- or 15-mm Endoscopic retrieval bag 5 mm suction/irrigation 5 mm atraumatic grasper

47.5.2 Positioning The patient is positioned supine with 30° of Trendelenburg, slightly rotated to the left (mostly supine but slight left lateral decubitus) if a right VATS is planned. A bump is placed under the chest. The ipsilateral arm is secured over the head of the patient with care taken to avoid brachial plexus and ulnar nerve injury. Surgeon and assistant stand on the ipsilateral side. The patient’s chest, cervical and subxiphoid region is prepped and draped widely (Fig. 47.1).

Fig. 47.1 Positioning Endoscope Working ports

Surgeon

Assistant

Scrub nurse

Instrument table

Monitor

Patient

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47.5.3 Trocar Placement

energy device is used (Milestone 47.3). When the internal mammary vessels are reached, the advanced energy device or hook cautery is changed from the right hand to left hand to aid in perpendicular dissection transversely across the superior mediastinum anterior to the innominate vein (Milestone 47.4) [1]. The dissection then proceeds inferiorly using superior traction to dissect the inferior poles of the thymus and prepericardial fat pad off the anterior pericardium (Milestone 47.5). Traction on the gland to the right helps visualize the left inferior pole of the thymus. Incising the left pleura may help visualize the left phrenic nerve. The dissection proceeds superior staying anterior to the left phrenic nerve (Milestone 47.6). An additional telescope can be useful for this part of the dissection. Once the pleura has been dissected circumferentially, the thymus is mobilized and retracted anterolaterally and dissected off the pericardium. Then, left lateral retraction helps visualize and enable dissection of the thymus from the innominate vein. Small vessels connecting the thymus to the innominate vein are taken with the advanced energy device or hook cautery. Larger branches should be

Local anesthesia is injected. We use a Veress needle and 5 mm step trocar at the anterior axillary line along the sixth intercostal space to gain access. It can be upsized later to a 10 mm trocar. A 30° telescope is inserted. The chest is insufflated with 3–5  mmHg and if the respiratory status allows pressure can increase to 8 mmHg. A middle port is placed in the mid axillary line and a superior port in the anterior axillary line to triangulate the lesion. If a bilateral approach is needed, additional 5 mm ports are inserted on the contralateral side.

47.6 Operative Milestones Dissection begins on the right side by incising the pleura just anterior to the right phrenic nerve running on top of and lateral to the superior vena cava (Milestones 47.1 and 47.2) until the right mammary vein is reached. A blunt grasper in conjunction with hook cautery or a bipolar or ultrasonic

Milestone 47.1 Identification of the phrenic nerve (Video 47.1 Thoracoscopic Thymectomy Video). (▸ https://doi.org/10.1007/000-2wa)

Milestone 47.3  Meticulous clipping/coagulation of the vessels

Milestone 47.4  Dissection of lower lobe Milestone 47.2  Incision of pleura

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47.7 Postoperative Care Chest tube is usually removed on first postoperative day. Pain management regimen consists of scheduled acetaminophen and non-steroidal anti-inflammatory drugs for 48 h, then as needed. Narcotics are not typically ordered unless a chest tube is left in place. Average length of stay has been reported as short as 1.6 days [6]. Surveillance for recurrence of thymoma is performed with chest CT with contrast every 6–12 months for 2 years then annually for 10 years.

47.8 Postoperative Complications Milestone 47.5  Dissection anterior to the innominate vein

Postoperative pericarditis especially in patients with myasthenia gravis has been reported after open and thoracoscopic thymectomy [7].

47.9 Pearls/Tips & Tricks

Milestone 47.6  Dissection of the superior lobe

individually dissected and clipped. Once the right superior thymic pole is dissected free, additional inferior traction enables dissection of the left superior thymic pole [1]. Often dissection must proceed significantly into the neck. Once the tail is free, the specimen is removed through the 10 mm trocar site using an Endo Catch bag. The specimen is marked with sutures and a drawing is made according to the recommendations from ITMIG.  The chest is re-insufflated and inspected. Residual disease such as accessory horns should be assessed for and may be located under the innominate vein. The pleural surfaces should be examined for pleural metastasis which should be resected to achieve complete gross resection. Hemostasis is verified. The right lung is ventilated and re-expanded under direct vision until all lobes are expanded. If no lung injury is noted or suspected and a chest tube is not placed, a red rubber catheter can be placed under water seal to evacuate air. The trocar sites are closed in layers. The red rubber catheter is removed while anesthesia provides a Valsalva to 30 cm H2O. A postoperative chest X-ray is performed.

1. Airway compression and hemodynamic effects of the mass should be considered. 2. If the thymus is midline or more to the right, a right-sided approach is usually performed, but for masses more to the left, a left chest approach is reasonable. The right side is usually preferred for midline masses because there is a larger right intrapleural space due to the anatomy. It is also easier to localize the innominate vein from the right side. However, localizing the left phrenic nerve from the right side can be more difficult as it is typically located more posteriorly on this side. A cervical incision can be added. 3. Lateral placement to avoid breast tissue is preferable in females. 4. If the resection is being done for thymoma or thymic carcinoma, surgical clips should be placed at areas of close margins, residual disease, or tumor adhesion to normal structures to guide radiation therapy. 5. Ectopic thymus can be found in cervical and mediastinal fat.

47.10 Pitfalls & Ways to Avoid Prevention of post op myasthenic crises can be attempted if indicated with preoperative intravenous immunoglobulins (IVIG). IVIG can be given if significant respiratory or bulbar symptoms or other risk factors are present. Care should also be taken to avoid significant blood loss in surgery to decrease the risk of myasthenic crisis. Risk factors for post op myasthenic crises include:

47  Thoracoscopic Thymectomy

1. Preoperative expiratory weakness 2. Preoperative vital capacity of less than 2 L 3. Preoperative bulbar symptoms 4. History of preoperative myasthenic crisis 5. Preoperative acetylcholine receptor antibody serum level of greater than 100 nmol/L 6. Intraoperative blood loss greater than 1000  mL (Video 47.1)

References 1. Whitson BA, Andrade RS, Mitiek MO, et  al. Thoracoscopic thymectomy: technical pearls to a 21st century approach. J Thorac Dis. 2013;5(2):129–34.

253 2. Kolski H, Vajsar J, Kim PC. Thoracoscopic thymectomy in juvenile myasthenia gravis. J Pediatr Surg. 2000;35(5):768–70. 3. Molinaro F, Garzi A, Cerchia E, et al. Thoracoscopic thymectomy in children: our preliminary experience. J Laparoendosc Adv Surg Tech A. 2013;23(6):556–9. 4. Hack HA, Wright NB, Wynn RF.  The anaesthetic management of children with anterior mediastinal masses. Anaesthesia. 2008;63(8):837–46. 5. Shamberger RC, Holzman RS, Griscom NT, et al. CT quantitation of tracheal cross-sectional area as a guide to the surgical and anesthetic management of children with anterior mediastinal masses. J Pediatr Surg. 1991;26(2):138–42. 6. Skelly CL, Jackson CC, Wu Y, et al. Thoracoscopic thymectomy in children with myasthenia gravis. Am Surg. 2003;69(12):1087–9. 7. Wanner WR, Williams TE, Fulkerson PK, Mendell JR, Leier CV.  Postoperativepericarditis following thymectomy for myasthenia gravis. A prospective study. Chest. 1983;83(4):647–9.

Thoracoscopic and Laparoscopic Approaches to Congenital Diaphragmatic Hernia (CDH)

48

Satoshi Ieiri, Kazuhiko Nakame, and Koji Yamada

48.1 I ndications for Minimally Invasive Approach for Congenital Diaphragmatic Hernia Minimally invasive surgery (MIS) has been gradually introduced for congenital diaphragmatic hernia (CDH) in neonates and infants because of recent advances in endoscopic surgery [1, 2]. CDH patients should be in a stable cardiovascular and respiratory condition before surgery. Those with severe pulmonary hypertension (PH) induced by persistent fetal circulation and management via extracorporeal membrane oxygenation (ECMO) are excluded or contraindicated for MIS [3]. Associated cardiovascular anomalies must also be ruled out. The lack of any marked changes in the cardiovascular and respiratory condition under the right lateral position before operation is a good way of assessing patients‘tolerance for CDH repair by thoracoscopy.

48.2 Preoperative Workup and Considerations CDH patients with Bochdalek hernia are often diagnosed prenatally by ultrasound and magnetic resonance imaging (MRI). Those who show symptoms of dyspnea and respiratory distress are sometimes diagnosed with CDH after delivery. Plain chest X-ray shows air-filled bowel loops in the hemithorax. CDH patients show a variable degree of PH. Mild cases of CDH are managed by insertion of a nasoSupplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_48. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. S. Ieiri (*) · K. Nakame · K. Yamada Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan e-mail: [email protected]

gastric tube and conventional ventilation. However, CDH children with moderate to severe PH require more intensive treatment, such as high-frequency oscillation (HFO) or ECMO. Recently, the MIS repair of CDH patients on ECMO was reported; however, adopting the MIS approach in this particular subgroup of patients is highly controversial [3].

48.3 Selection of the Operative Approach The thoracoscopic rather than the laparoscopic approach is usually selected for neonatal patients because the abdominal cavity of neonates is relatively small compared to late-­ presenting infantile cases. In addition, thoracoscopic reduction of the spleen and liver is easier than similar laparoscopic maneuvers. However, one drawback of the thoracoscopic approach is the costal restriction of instrument handling.

48.4 Anesthetic Considerations MIS for CDH is performed under general anesthesia and endotracheal intubation. CDH patients should be managed by experienced pediatric anesthesiologists. Intraoperatively, hypercapnia and hypoxia should be expected. Intraoperative hemorrhage is rare.

48.5 Operative Technique 48.5.1 Equipment • • • • •

3.5- or 5-mm instruments and trocars 3.5- or 5-mm 30° (45°) rigid scope 5- or 5-mm atraumatic grasper 3.5- or 5-mm needle holder 3.5- or 5-mm hook monopolar cautery

Suture material: 2-0 or 3-0 non-absorbable ethylene terephthalate braided sutures

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_48

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48.6 Thoracoscopic Approach

48.6.3 Milestones

48.6.1 Positioning

After placement of the endoscopic trocars and insertion of two working trocars, the operation begins with the identification of the herniated organs and a possible hernia sac. If a hernia sac is present, there are no herniated organs in the thoracic cavity. When no hernia sac is present, the contents of the left thoracic cavity usually consist of the herniated stomach, small intestine, colon, spleen and (in large defects) liver. The first step of the operation is the reduction of the herniated organs. Initially, the bowel should be reduced by gentle manipulation using an atraumatic grasper and cotton dissector. Reduction of the spleen requires careful manipulation [4]. Grasping the spleen may induce injury and bleeding. Splenic reduction should be performed by gentle manipulation and not by grasping (Milestone 48.1). In the absence of a sac, the muscular borders should not be defined. When the posterior rim of the diaphragm is recognized, closure of the native diaphragm is possible. In selected cases, posterior stiches/sutures need to incorporate the adjacent posterior ribs. Interrupted nonabsorbable sutures (e.g. 2-0 or 3-0 ethylene terephthalate) are used. Both intraand extracorporeal knots may be tied, depending on the surgeon’s choice and skills. We use pre-tied knots (Loeder’s knot) to close defects (Milestone 48.2). Closure of the most lateral side of the diaphragm is always challenging, as recurrence in this area is possible. If possible, a bridging suture over the adjacent rib is recommended. For this maneuver, we use a needle loop device [5] (Milestone 48.3). When the diaphragmatic defect is too large for direct closure, a patch (expanded polytetrafluoroethylene membrane: e-PTFE membrane, 2 mm thickness) is needed. The fixation of this patch is performed using non-absorbable interrupted sutures or clip application (titanium or polymer clip).

The patient is placed in the right lateral position on the table. Depending on the width of the operation table, the patient may be placed transversely on the table. The operating surgeon stands at the patient’s head, and the monitor is placed opposite to the surgeon. The operator’s co-axial position for the target organ (left diaphragmatic defect, posterolateral side) is favorable. The assistant stands next to the surgeon, and the scrub nurse stands on the opposite side of the surgeon (Fig. 48.1).

48.6.2 Trocar Placement The first trocar is placed in the fourth intercostal space (ICS) of the middle axillary line using optical methods. After the insertion of the endoscopic trocar, capnothorax is established at 0.5–1 L/min with a maximum pressure of 4–6 mmHg. The CO2 pressure and flow should be limited and modified depending on the patients’ condition (e.g. CO2 insufflation may be turned off once the viscera are reduced into the abdominal cavity). Under inspection with an endoscope, two working trocars are inserted. The anterior trocar is placed in the fifth or sixth ICS at the anterior axillary line for the operator’s right hand, and the posterior trocar is placed just below the inferior tip of the scapula for the operator’s left hand. The left-hand trocar placement between the endoscopic trocar and spine allows for a relatively free range of movement of the instruments (Fig. 48.1).

Fig. 48.1  Positioning and trocars placement of thoracoscopic approach

Positioning and Trocars Placement (Thoracoscopic Approach)

Patient Monitor Surgeon Assistant Scrub nurse Instrument table

Working trocar Endoscopic trocar

48  Thoracoscopic and Laparoscopic Approaches to Congenital Diaphragmatic Hernia (CDH)

a

Milestone 48.1 (a) Reposition of bowel loops by gentle manipulation using such as atraumatic graspers and cotton dissectors. (b) Grasping the spleen may induce injury and bleeding. Splenic reduction should be

a

Milestone 48.2 (a) If a sac is absent, the muscular borders should not be violated. When the posterior rim of the diaphragm is recognized, closure of the own diaphragm is possible. (b) In order to perform a secure closure of the diaphragm and to prevent recurrence, interrupted

257

b

performed by gentle manipulation (Video 48.1 Movie with narration). (▸ https://doi.org/10.1007/000-2wb)

b

non absorbable sutures (2-0 or 3-0 polyester or ethylene terephthalate) are used. Both intra and extracorporeal knots may be placed depending on the surgeon’s choice and skills

in neonates. Furthermore, handling the organs and needle driving is easier in infants than in neonates with a laparoscopic approach.

48.7.1 Positioning

Milestone 48.3  If necessary, a suture encircling the adjacent rib is placed to close the lateral defect. A loop or lasso technique can be used to accomplish this stich

48.7 Laparoscopic Approach Late-presenting CDH has been treated via both thoracoscopic and laparoscopic approaches. In cases without herniation of the spleen into the thoracic cavity, a laparoscopic approach is easier to use when repairing the diaphragm because of the lack of costal restriction and a wider working space compared to the thoracic technique. The abdominal cavity of infants under pneumoperitoneum is larger than that

The patient is placed in the right semi lateral position on the operation table. The surgeon stands at the patient’s right side or foot, and the monitor is placed opposite the surgeon. The operator’s co-axial position for the target organ (left diaphragmatic defect, posterolateral side) is favorable. The assistant stands next to the surgeon, and the scrub nurse stands on the opposite side of the surgeon (Fig. 48.2).

48.7.2 Trocar Placement The first trocar is placed at the umbilicus using an open technique. After the insertion of the laparoscopic trocar, pneumoperitoneum is established by CO2 insufflation at 1–2 L/min with a maximum pressure of 6–8 mmHg. Under laparoscopy, two working trocars are inserted in a coaxial fashion. The trocar for the operator’s left hand is placed in the right upper

258 Fig. 48.2  Positioning and trocars placement of laparoscopic approach

S. Ieiri et al.

Patient Monitor Surgeon Assistant Scrub nurse Instrument table

Working trocar Endoscope trocar

abdomen, and the posterior trocar for the operator’s right hand is placed on the left side of the umbilicus. We arrange our trocar positions based on intraoperative laparoscopic findings and the shape and size of the diaphragmatic defect (Fig. 48.2).

a

48.7.3 Milestones After placement of the scope trocars through umbilicus and insertion of two working trocars, the operation begins with the identification of the herniated organs and a possible hernia sac. If a hernia sac is present, there are no herniated organs in the thoracic cavity. When no hernia sac is present, the contents of the left thoracic cavity usually consist of the herniated stomach, small intestine, colon, spleen and (in large defects) liver. The reduction of the herniated organs is performed by mainly pulling maneuver, so atraumatic grasper is recommended. If spleen is herniated, grasping the spleen should be avoided because of risk of bleeding. Spleen sometimes would be reduced with the reduction of stomach. When the posterior rim of the diaphragm is recognized, closure of the native diaphragm is possible. In selected cases, posterior stiches/sutures need to incorporate the adjacent posterior ribs. Interrupted non-absorbable sutures (e.g. 2-0 or 3-0 ethylene terephthalate) are used. Both intra- and extracorporeal knots may be tied, depending on the surgeon’s choice and skill. We use pre-tied knots (Loeder’s knot) to close defects (Milestone 48.4).

b

Milestone 48.4 (a, b) Interrupted non-absorbable sutures (e.g. 2-0 or 3-0 ethylene terephthalate) are placed. Both intra- and extracorporeal knots may be tied, depending on the surgeons choice and skills. Pre-tied knots (Loeder’s knots) are useful

48  Thoracoscopic and Laparoscopic Approaches to Congenital Diaphragmatic Hernia (CDH)

48.8 Postoperative Care The postoperative management depends on the patient’s cardiovascular and respiratory condition, especially the presence of PH. In general, the respiratory condition may (but does not necessarily) improve because of the reduction of the herniated organs. The long-term outcome is determined by the degree of lung hypoplasia and corresponding PH.

48.9 Pearls/Tips & Tricks 1. Accurately evaluating a patient’s tolerance for the MIS approach is important when selecting the operative procedure. The preoperative estimation of the defect size of the diaphragm is very difficult, but the detection of herniated organs, especially a “liver-up situation” and the spleen and kidney, is feasible using ultrasonography and computed tomography. 2. If a patient’s condition is unstable under artificial capnothorax and pneumoperitoneum, do not hesitate to convert to laparotomy. If the defect of the diaphragm is too large and difficult to close with the patient’s own tissue, consider using a patch. 3. The endtidal CO2 should not be elevated up to 70–80 mmHg during the operative procedures. Close collaboration with the anesthesiologist is recommended to avoid hypercapnia, hypoxia and acidosis. 4. Artificial pneumothorax using CO2 helps to reduce the viscera from the thoracic to the abdominal cavity. 5. Start with a low pressure (maximum of about 6 mmHg) in artificial pneumothorax. 6. Reduce the spleen last and use it as a cap on top of the bowel to occupy the diaphragmatic defect.

259

7. Once the organs are reduced from the thorax into the abdomen and the first stiches are completed CO2 can often be turned off to avoid its side effects.

48.10 Pitfalls & Ways to Avoid 1. Avoiding organ injury is most important during reduction of the herniated organs. The spleen and its vessels are at particular risk, so gentle and careful manipulation of the herniated organ is mandatory. 2. Closure of the posterolateral side of the defect is challenging. Extracorporeal needle insertion through an intercostal space and tying the knot over a rib is a helpful technique (Video 48.1 Movie with narration).

References 1. Weaver KL, Baerg JE, Okawada M, Miyano G, Barsness KA, Lacher M, Gonzalez DO, Minneci PC, Perger L, St Peter SD.  A multi-­ institutional review of thoracoscopic congenital diaphragmatic hernia repair. J Laparoendosc Adv Surg Tech A. 2016;26(10):825–30. 2. Clifton MS, Wulkan ML. Congenital diaphragmatic hernia and diaphragmatic eventration. Clin Perinatol. 2017;44(4):773–9. https:// doi.org/10.1016/j.clp.2017.08.011. 3. Desai AA, Ostlie DJ, Juang D.  Optimal timing of congenital diaphragmatic hernia repair in infants on extracorporeal membrane oxygenation. Semin Pediatr Surg. 2015;24(1):17–9. https://doi. org/10.1053/j.sempedsurg.2014.11.004. 4. Kawano T, Muensterer OJ.  A new gentle reduction technique for patients with congenital diaphragmatic hernia-a case report. Int J Surg Case Rep. 2019;57:5–8. https://doi.org/10.1016/j. ijscr.2019.03.001. 5. Nakame K, Onishi S, Yano K, Murakami M, Kawano M, Baba T, Harumatsu T, Yamada K, Yamada W, Masuya R, Kawano T, Machigashira S, Mukai M, Kaji T, Ieiri S.  Effectiveness of simulator training mimicking a patient’s specific situation for neonatal congenital diaphragmatic hernia. J Laparoendosc Adv Surg Tech A B:Videoscopy. 2019;29(1).

Minimally Invasive Repair of Pectus Excavatum (MIRPE)

49

Sergio B. Sesia and Gregor J. Kocher

49.1 I ndications for Minimally Invasive Repair Pectus excavatum (PE) or funnel chest is the most common congenital chest wall deformity in children and adolescents. It is characterized by an abnormal growth of the sternocostal joints, resulting in a caved aspect of the anterior chest wall. Its estimated incidence is at least 1 to 400 births with a male predominance (male to female ratio 4:1) [1]. Only patients with a severe defect and an associated pulmonary and/or cardiac impairment should be considered for minimally invasive repair of PE (MIRPE) [2]. At least two of the following criteria should be fulfilled before MIRPE is indicated [2, 3]: a. Shortness of breath, lack of endurance or dyspnea on exertion b. Increase of PE during pubertal spurt c. Cardiac and/or pulmonary compression on computed tomography of the chest d. Compression or displacement of the heart, mitral valve prolapse, conduction abnormalities on echocardiography e. Restrictive or obstructive pulmonary pattern on pulmonary function studies f. Haller Index (ratio of the transverse breadth of the chest cavity and the narrowest sternovertebral distance, at the level of the deepest point of PE) greater than 3.25 g. Severe body image disturbance (i.e. social isolation, depression)

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_49. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. S. B. Sesia (*) · G. J. Kocher Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland e-mail: [email protected]; [email protected]

Since the heart, the pulmonary parenchyma, and the airways in PE patients are generally healthy [4], cardiopulmonary impairments in PE patients are not universally present. Patients with mild PE should be offered nonoperative treatment, i.e. physiotherapy with exercise, posture program and the use of the vacuum bell, since its efficacy is documented [5, 6]. Pathological pulmonary function tests and/or cardiac evaluation and/or physiological impairment and/or a depth of PE of more than 3 cm characterize a severe PE [3]. The ideal time for MIRPE is in the adolescence [2]. However, successful repair of PE has been reported also in prepubertal and adult patients [7].

49.2 Preoperative Workup and Considerations To determine the severity of PE and indicate MIRPE, PE patients undergo history evaluation, physical examination, pulmonary function tests, echocardiography and chest computed tomography or Magnetic Resonance Imaging (MRI) in adolescent patients. The depth of the PE is measured with a rod. To determine the length of the pectus bar to implant, the chest at the deepest point of the defect is measured from right to the left midaxillary line. Considering that the pectus bar is placed under the subcutaneous tissue, 1 Inch or 2 cm has to be subtracted from this value. Finally, it is mandatory to identify a potential metal allergy. In case of patient or family history of metal allergy and a positive patch testing, a titanium pectus bar should be implanted. Usually, one pectus bar is sufficient to correct PE. In older patients, stiffer chests or asymmetric defect, the use of more than one bar should be considered. In order to learn breathing with an implanted pectus bar and to prevent pneumonia postoperatively, PE patients should already begin preoperatively with intensive respiratory exercises and the use of a spirometer.

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_49

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Qualified patients for MIRPE, but with a PE depth between 2 and 3 cm may benefit from the use of the vacuum bell preoperatively, in order to soften the anterior chest wall. For a potential need of blood transfusion, all patients must have their blood typed and screened preoperatively. For the case of uncontrolled bleeding or cardiac injury, a sternotomy saw and defibrillator should be available in or near the operating room.

49.3 Anesthetic Considerations MIRPE is performed under general endotracheal and thoracic epidural anesthesia and hemodynamic monitoring. Because of epidural analgesia and subsequent urinary retention, an indwelling Foley catheter is placed. In order to facilitate thoracoscopic visualization of the procedure a double lung intubation is used. At least two peripheral intravenous catheters should be in place. In order to prevent pectus bar infection, 1.5 g cefuroxime i.v. as single-shot is administered 30 min. before the skin incision.

49.4 Operative Technique 49.4.1 Equipment • • • • • • • •

5 mm instruments and trocars 5 mm 30° angled thoracoscope Pectus bar template Pectus bar, stabilizer, pectus bar bender, pectus introducer L and XL (for severe deformities), pectus bar flipper Size- and gender-appropriate sterilized vacuum bell Bending press and or bending wrench Monopolar electrocautery Langenbeck retractor, bone hook

Fig. 49.1  Positioning of the patient, surgeons and monitors

• Braided polyester tape ribbon (to be fixed to the tip of the introducer once it is passed underneath the sternum to lift up its tip and to prevent stripping of intercostal muscles, furthermore the prebent pectus bar is then attached to this tape and retracted into place)

49.4.2 Positioning Supine position with the right arm over the head and the left arm abducted around 70° in order to avoid brachial plexus injury [3]. Both elbows are fixed. It is important to expose the entire anterior chest including the lateral chest wall. The surgeon stands on the right side, with the monitor on the opposite side. The assistant stands on the left side, the scrub nurse to the right side of the surgeon (Fig. 49.1).

49.4.3 Marking the Chest Before making the skin incision, it is important to mark the deepest point of the defect (point where the pectus bar has to pass under), the entry and exit site where the pectus introducer goes in and out of the chest (ideally situated right medially to the edges of the cave), and the two skin incisions (between the anterior and the mid-axillary line) (Fig. 49.2). If the deepest point of the pectus is at xiphoid level or lower, probably more than one pectus bar should be considered for implantation.

49.4.4 Trocar Placement Once the right lung is excluded from ventilation, a 5-mm blunt trocar is inserted either two intercostal spaces above or below the skin incision on the right side. Thoracoscopy allows to identify

Legend

Patient

Monitor Incision Surgeon Assistant Scrub nurse Anesthesist Instrument table

49  Minimally Invasive Repair of Pectus Excavatum (MIRPE)

263

Fig. 49.3  Advancing the pectus introducer behind the sternum under thoracoscopic control and with the vacuum bell in place Fig. 49.2  Marking of the chest. C—camera, positioned 2 intercostal spaces above the planned lateral incision on the right; in—entry point: out 1 & 2—exit points: option 1 for a horizontal and option 2 for an oblique bar position (preferred); x—lower end of the sternum (xiphoid). The x in the middle marks the deepest point of the excavation

Milestone 49.2  Performing the retrosternal dissection under thoracoscopic view and using the vacuum bell

Milestone 49.1  Placing the vacuum bell for sternal elevation (Video 49.1 MIRPE). (▸ https://doi.org/10.1007/000-2wc)

potential intrathoracic pathologies, and to confirm whether the chosen entry point on the right side is in line with the deepest point of the pectus and the corresponding intercostal space. In female patients, a submamary incision is used. In case of a very steep rear part of the sternum, probably more than one pectus bar should be evaluated.

49.4.5 Operative Milestones After removal of the thoracoscope, a subcutaneous tunnel is created from the skin incisions to the previously selected entry points. On the right side, the skin pocket is extended laterally to allow the placement of the stabilizer. Under thoracoscopic control, the chest cavity on the right is entered with the blunt tip of the pectus introducer at the marked entry point. As a next step, the vacuum bell is placed over the deformity and connected to the suction (Milestone 49.1; Fig. 49.3) whereas the subsequent elevation of the sternum can be verified thoracoscopically [8].

The retrosternal dissection is performed by gentle up- and down movements, continuously freeing up the pericardium from the posterior part of the sternum. During the entire retrosternal dissection, the tip of the introducer is under constant view (Milestone 49.2) with the vacuum bell in place, and the tone of the ECG monitor is turned up in order to better recognize any arrhythmia. Once the tip of the introducer exits at the marked point on the left side, a mersilene tape is attached at the end of the introducer. The assistant applies opposing forces to the surgeon who pushes the pectus introducer from right to left, while at the same time pulling the introducer’s tip upwards in a vertical direction. This maneuver prevents stripping of the intercostal muscles on the left side. The chest cavity including the pericardium is inspected again by thoracoscopy. To remodel the anterior chest wall and the costal arches, the introducer is lifted up on both sides while the surgeon molds the costal cartilage by pushing down the anterior chest and the costal arches. A template is used to determine the optimal length and desired shape of the pectus bar to be implanted. The final bar should be long enough to allow the placement of a stabilizer on the right side and to overlap two ribs on the left side, after it has exited the chest (Milestone 49.3).

264

Milestone 49.3  Use of template to determine bar length and shape

The pectus bar with the desired length is now shaped, using a bending press (see video) or a bending wrench, until it has exactly the shape of the template. The middle of the pectus bar should be flat to support the sternum. The preshaped pectus bar is now attached to the end of the pectus introducer with the mersilene tape. Under thoracoscopic view, the introducer is withdrawn and the pectus bar retracted through the chest from the left to the right side. Alternatively, the introducer is withdrawn only with the mersilene tape attached to its tip. Then, the bar is inserted from right to left into the chest cavity. Finally, once the pectus bar is inserted (the insertion is carried out with the convexity of the pectus bar facing upwards), a bar flipper is attached to the right end of the bar and a bone hook to the left side (alternatively two bar flippers can be used, each on one end of the bar) and the pectus bar is rotated into its final position. Once in place, the stability of the pectus bar is verified by simply trying to rotate the bar back with two fingers. If this maneuver allows to flip the bar back easily, two stabilizers (one on each side) should be considered to ascertain a better stability of the bar. If the bar is already quite stable (which is mostly the case), only one stabilizer is inserted on the right side. The final position of the stabilizer should be as close as possible to the previously highest point of the chest (i.e. hinge point: in Fig.  49.2 marked with a dashed line; Milestone 49.4). Finally, the right end of the bar is bent towards the chest, which definitely prevents the stabilizer from moving laterally. In case the bar end on the left is not touching the chest wall and still protruding under the skin, also this end should be bent, using the bar flipper or a bending wrench, until it fits the shape of the chest wall. As said, on the side without stabilizer, the bar end should overlap at least two ribs in order to avoid secondary dislocation.

S. B. Sesia and G. J. Kocher

Milestone 49.4  Placement of the stabilizer near the hinge point

a

b

Fig. 49.4 (a) preoperative view; (b) view after final placement of the pectus bar

A last visualization of the inside of the chest cavity is done, now that the bar has reached its final position to exclude any bleeding sites (Fig. 49.4)—especially from the mammarian vessels and the entry point of the bar. While the skin incisions are sutured, a small suction catheter is introduced at the former camera site and placed under a water seal. The anesthesiologist now ventilates both lungs with positive pressure ventilation until no air is coming out of the catheter anymore. After applying a subcutaneous purse string suture around the catheter, the catheter is finally connected to the suction device to evacuate any possible residual pneumothorax and the catheter is withdrawn and removed and the purse string suture is tied. The skin is closed with intracutaneous running sutures and skin patches are applied (Fig. 49.5).

49  Minimally Invasive Repair of Pectus Excavatum (MIRPE)

265

3. Pectus bar does not necessarily need to be placed perpendicularly to the sternum (i.e. in a horizontal position). Especially in asymmetric deformities, often a better cosmetic result and a more stable position of the pectus bar can be achieved with a bar position obliquely to the sternum. 4. Positioning the stabilizer as close as possible to the entry point (hinge point) prevents secondary bar displacement. 5. Overlapping of at least two ribs on the side without stabilizer prevents secondary bar displacement.

49.7 Pitfalls & Ways to Avoid Fig. 49.5  Final postoperative result including postoperative chest X-ray

1. Marking the landmarks is helpful for choosing the right length and the right position of the pectus bar 2. Overbending the central part of the pectus bar may lead to 49.5 Postoperative Care secondary displacement 3. The tip of the pectus introducer must be in view at all times during retrosternal dissection Postoperatively, once the patient is extubated, an antero-­ posterior chest X-ray is made in the recovery room to exclude 4. When emerging the pectus introducer on the left side, the risk of stripping the intercostal muscles can be minimized any significant residual pneumothorax. Postoperative analby lifting the tip up vertically with a mersilene tape gesia includes epidural catheter, intravenous morphine and nonsteroidal anti-inflammatory drugs. In order to prevent a bar dislocation patient mobilization is only permitted en-­ bloc for the first two weeks after surgery. Sport activities and References rotational trunk movements should be avoided for 3 months 1. Hebra A.  Minimally invasive repair of pectus excavatum. Semin after surgery. Thorac Cardiovasc Surg. 2009;21:76–84. The epidural catheter is usually removed 3 to 5 days after 2. Frantz FW. Indications and guidelines for pectus excavatum repair. surgery, when the patient is fully ambulatory. Physical therapy Curr Op Ped. 2011;23:486–91. as well as the use of the spirometer at least once per day are 3. Nuss D, Kelly RE Jr. The minimally invasive repair of pectus excavatum. Op Tech Thorac and Cardiovasc Surg. 2014;19:324–47. mandatory. The hospital stay usually varies from 4 to 7 days.

49.6 Pearls/Tips & Tricks 1. CO2 insufflation up to 8-mm Hg can be useful to allow even better visualization and is mandatory in case of single-­lumen endotracheal intubation. 2. The use of the vacuum bell facilitates retrosternal dissection. However, please note that the low-temperature gas plasma procedure we use to sterilize the vacuum bell preoperatively is a “off-label”-use, but approved by our Department of Hospital Hygiene and Infection Control. The vacuum bell should be used at the discretion and responsibility of the surgeon.

4. Kelly RE, Goretsky MJ, Obermeyer R, Kuhn MA, Redlinger R, Haney TS, Moskowitz A, Nuss D. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg. 2010;252:1072–81. 5. Sesia SB, Hradetzky D, Haecker FM. Monitoring the effectiveness of the vacuum bell during pectus excavatum treatment: technical innovation. J Pediatr Surg. 2018;53:411–7. 6. Togoro SY, Tedde ML, Eisinger RS, Okumura EM, de Campos JRM, Pêgo-Fernandes PM.  The vacuum bell device as a sternal lifter: an immediate effect even with a short time use. J Pediatr Surg. 2018;53:406–10. 7. Pilegaard HK. Extending the use of Nuss procedure in patients older than 30 years. Eur J Cardiothorac Surg. 2011;40:334–8. 8. Haecker FM, Sesia SB.  Intraoperative use of the vacuum bell for elevating the sternum during the Nuss procedure. J Laparoendosc Adv Surg Tech A. 2012;22:934–6.

Thoracoscopic Sympathotomy with Sympathicolysis (TS) for Primary Palmar Hyperhidrosis (PPH) in Children

50

Adam Mol

50.1 Indications for Thoracoscopic Approach to Primary Palmar Hyperhidrosis There is no clear definition for a severe primary palmar hyperhidrosis (PPH). In clinical practice the only diagnostic examination would be a handshake. However, when other treatments failed severe PPH is associated with a psychological burden and causing serious social problems. For severe PPH, the only permanent solution is thoracoscopic sympathicolysis (TS). Excessive moisture of the hands is no indication for TS, as this condition does not necessarily cause somatic illness and is considered an extreme form of a physiologic state. The indication for the TS is made when two criteria are fulfilled: psychological suffering and willingness to undergo the surgical procedure. A professional psychological evaluation might be helpful and is required to confirm the indication in some countries. Young age itself should not be considered a contraindication as in children the satisfaction rate after the procedure is generally higher than in the adult population [1–3].

50.2 Preoperative Workup and Considerations The diagnosis of PPH in children is based on history and physical examination. An onset in early childhood and family history are often reported. Bilateral symmetrical manifes-

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-3-030-58043-8_50. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. A. Mol (*) Department of Pediatric Surgery, University Children’s Hospital, Cracow, Poland

tation limited to hands or hands-feet in combination with absence of nighttime sweating are further indicators for PHH. Generalized sweating, on the other hand, indicates an underlying disease that should be excluded before performing surgery. Different methods of sweat measurement have been described, however none of them found their way into clinical practice and only a handshake with confirmed intense moisture of the hands confirms the diagnosis.

50.3 Anesthetic Considerations Thoracoscopic sympathotomy with sympathicolysis is performed under general anesthesia only. A purely selective operation is performed bilaterally in an ambulatory setting (as outpatient surgery). Conventional single-lumen endotracheal intubation is sufficient to safely perform the procedure (selective bronchial intubation, recommended sometimes, is not necessary). An intrathoracic working space is usually achievable with very low-pressures of carbon dioxide insufflation (around 5  mm Hg) facilitated by semi-sitting position of the patient. Once the procedure is performed, residual intrathoracic gas is evacuated via small rubber tube inserted thorough the trocar opening: we ask the anesthetist to exert continuous positive pressure several times (Valsalva maneuver), gradually withdrawing the intrathoracic end of the tube. This technique makes a postoperative radiograph unnecessary, as well as placement of a postoperative chest tube.

50.4 Operative Technique 50.4.1 Equipment • 3 or 5 mm instruments and trocars (2 for each side) • 3 or 5 mm 0° laparoscope • 3 or 5 mm bipolar forceps

© Springer Nature Switzerland AG 2021 M. Lacher, O. Muensterer (eds.), Video Atlas of Pediatric Endosurgery (VAPE), https://doi.org/10.1007/978-3-030-58043-8_50

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• 3 or 5 mm hook monopolar cautery (grounding pad) • small rubber tube

50.5 Positioning We pay a lot of attention to the positioning of the patient, which not only facilitates the procedure but reduces postoperative pain as well. A patient is placed in semi-sitting position with 90° abduction of the arms sideways and the elbows slightly flexed. We fasten the patient to the operating table with a belt around the hips to maintain the semisitting position  (Fig.  50.1). This position changes the gravity vector of the lung which should make it slide down intraoperatively, naturally allowing us to use low intrathoracic pressures, and at the very same time providing excellent exposure of the operative area. The surgeon and the first assistant both stand on the ipsilateral side. The monitor is placed at the head of the bed, always slightly contralateral to the operating side.

Fig. 50.2  Trocar positioning: Note the placement of the second trocar along the inframammary fold

50.6 Trocar Placement Two 3 or 5-mm incisions are made after the skin is injected with local anesthesia: The first in the mid axillary line in the third intercostal space, the second slightly anteriorly in the fifth intercostal space (Fig. 50.2). If the inframammary fold is visible, the second incision is placed in this fold to achieve better postoperative esthetics. The first of the two (3 or 5 mm) trocars is placed using the open technique in apnea ventilation mode, in order to minimalize risk of injuring the lungs. Placement of the second trocar is under vision with the lung already collapsed.

Fig. 50.1  Positioning of the patient. Note the semi sitting position with flexed arms and knees

Milestone 50.1  Localization of the second rib (Video 50.1 Hiperhidrosis 4mp4_update_2020). (▸ https://doi.org/10.1007/000-2wd)

50.7 Operative Milestones The operation begins with identification of the sympathetic chain and of the second rib  (Video 50.1). Clear identification of the second (the highest visible rib in the thoracic cavity) is crucial as this rib serves as the reference point for determining the location and level of the ganglia (Milestone 50.1). A bilateral T2–T3 sympathicolysis (bipolar electrofulguration) starts at the point of the simplest chain identification. To confirm its proper location we perform the “guitar cord tensing maneuver”: with a bipolar forceps we push the sympathetic chain laterally which would tense and in this manner become more visible under the parietal pleura (Milestone 50.2). For adequate treatment, the distance from just below the second rib going down to the head of the fourth rib requires electrofulguration. In doing so, the sympathetic chain tenses and “draws” itself below the parietal pleura (the pleura is never opened), making identification of the sympathetic chain even easier (Milestone 50.3). Here, the electrofulguration is executed with short single impulses, thereby avoiding the dispersion of thermic energy along the chain

50  Thoracoscopic Sympathotomy with Sympathicolysis (TS) for Primary Palmar Hyperhidrosis (PPH) in Children

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Milestone 50.4  A 3  cm long transversal transection of the parietal pleura and periosteum is performed along the third and fourth ribs (D3-­ D4/R3-R4)

Milestone 50.2  Guitar tensing maneuver (2 Fotos). The white string under the parietal pleura corresponds with the sympathetic chain

Milestone 50.3  While applying electrofulguration the sympathetic chain tenses and “draws” itself below the parietal pleura (the pleura is never opened), making identification of the sympathetic chain even easier

instrument. At the moment of chain disruption (sympathotomy), its ends would separate automatically because of the chain’s natural contraction forces induced by electrofulguration which confirms an adequate technique. According to the international nomenclature [4], we perform sympathicolysis below the level of R2 to R4 (R referring to rib, and the number referring to which rib) with sympathotomy at the levels R3, R4. Such technique provides destruction of the second and the third ganglia with disruption of the possible collateral nerves (Knutz) [5]. After the procedure, residual air is evacuated via a small rubber tube placed through one of the trocars (Milestone 50.5). We ask the anesthetist to exert continuous positive pressure several times. The proximal end of the rubber tube is kept under water in a basin, while slowly and gradually the distal intrathoracic end of the tube is withdrawn. After the termination of bubbling, which confirms the complete evacuation of the intrathoracic air, the tube is removed. The analogue procedure is performed on the contralateral side. We no longer use postoperative chest tubes nor perform postoperative radiographs on a routine basis.

50.8 Postoperative Care and to the adjacent structures. In such manner, injury of the stellate ganglion and as a consequence, the risk of Horner’s syndrome, is minimized. Subsequently, a 3  cm long transversal transection of the parietal pleura and periosteum is performed along the third and fourth ribs (D3-D4/R3-R4) (Milestone 50.4). The direction of dissection is always oriented from medial to lateral, commencing at the actual chain out laterally and transecting it by pressing the chain with the hook down on the rib. Using a medial to lateral approach avoids injury of the mediastinum through potentially uncontrolled movements of the

We recommend avoiding excessive physical activities for a period of 1 week. Oral analgesics are prescribed at discharge. If hands’ dryness is perceived as too excessive, we recommend usage of moisturizing creams locally for a few weeks. The procedure may be performed in an outpatient setting. Regular postoperative evaluations over the period of 3 years are needed to determine and quantify the appearance of compensatory sweating, as well as to rule out recurrence. Disease-specific patient’s satisfactory rate can be measured by the Hyperhidrosis Quality of Life Index (HidroQoL) [6].

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5. The insertion of the first trocar is performed using the open technique in apnea ventilation mode. Once an intrathoracic location is confirmed, the insufflation is started and normal lung ventilation mode is resumed a few ­seconds afterwards—this facilitates the creation of the working space 6. Movements of the instruments should be always made towards the periphery, away from the mediastinum 7. Short electrofulguration impulses limit the destruction to the local sympathetic chain and thereby lowering the risk of injuring neighboring ganglia 8. Evacuation of the entire intrathoracic gas via a rubber tube reduces the postoperative pain

50.10 Pitfalls & Ways to Avoid 1. Misinterpretation of the surgical anatomy, especially the localization of the ganglia can lead to Horner’s syndrome 2. There is no need for resection of the ganglia, dissection is sufficient 3. Leaving intrathoracic gas causes significant postoperative pain in our experience 4. Even if residual gas is found on postop radiographs (iatrogenic pneumothorax), a chest tube is unnecessary in an otherwise stable patient, as the CO2 will dissolve spontaneously

References Milestone 50.5  Evacuation of the entire intrathoracic gas via rubber tube (3 pictures)

50.9 Pearls/Tips & Tricks 1. The risk of compensatory sweating in the postoperative period should be explained preemptively to the patient 2. It is crucial to clearly identify the second rip before starting the dissection 3. Guitar cord tensing maneuver for better visualization of the sympathetic chain 4. The semi-sitting position facilitates the procedure by providing exposure at low insufflation pressures. If necessary, sometimes an initial gentle downward push of the lung with the instrument allows access to the ganglia

1. Steiner Z, Kleiner O, Hershkovitz Y, Mogilner J, Cohen Z. Compensatory sweating after thoracoscopic sympathectomy: an acceptable trade-off. J Pediatr Surg. 2007;42(7):1238–42. 2. Steiner Z, Cohen Z, Kleiner O, Matar I, Mogilner J.  Do children tolerate thoracoscopic sympathectomy better than adults? Pediatr Surg Int. 2008;24(3):343–7. 3. Laje P, Rhodes K, Magee L, Klarich MK, Pediatric Surgery J.  Thoracoscopic bilateral T3 sympathectomy for primary focal hyperhidrosis in children. J Pediatr Surg. 2017;52(2):313–6. 4. Cerfolio RJ, De Campos JR, Bryant AS, et  al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg. 2011;91:1642–8. 5. Ramsaroop L, Singh B, Moodley J, Partab P, Satyapal KS. Anatomical basis for a successful upper limb sympathectomy in the thoracoscopic era. Clin Anat. 2004;17:294–9. 6. Kamudoni P, Mueller B, Salek MS. The development and validation of a disease-specific quality of life measure in hyperhidrosis: the Hyperhidrosis Quality of Life Index (HidroQOL©). Qual Life Res. 2015;24(4):1017–27.